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Interagency Safeguarding Children ProceduresNottinghamshire Safeguarding Children Board (NSCB)
Nottingham City Safeguarding Children Board (NCSCB)

Unexpected Death of a Child

SCOPE OF THIS CHAPTER

This Chapter sets out the processes to be followed when a child dies in the Nottinghamshire (NSCB) and Nottingham City (NCSB) Local Authority areas as set out in Working Together to Safeguard Children (2015). There are two interrelated processes for reviewing child deaths (either of which can trigger a Serious Case Review (Chapter 5 in Working Together):

  1. Rapid response by a group of key professionals who come together for the purpose of enquiring into and evaluating each unexpected death of a child;
  2. An overview of all child deaths up to the age of 18 years (excluding both those babies who are stillborn and planned terminations of pregnancy carried out within the law) in the LSCB area(s) undertaken by a panel.

This chapter was taken from the last version of the Interagency Safeguarding Children Procedures of the Nottinghamshire Safeguarding Children Board (NSCB) and the Nottingham City Safeguarding Children Board (NCSCB) Procedure, September 2014. It retains references to Working Together 2015 and the Safeguarding Authority (ISA).

See also: Sudden unexpected death in infancy and childhood Multi-agency guidelines for care and investigation (November 2016).

AMENDMENT

This chapter was updated in June 2017 with a link to the guidance from the Royal College of Pathologists.

Contents

  1. Child Death Overview Panel
  2. Rapid Response to Unexpected Child Deaths
  3. Appendix 1: Form A - Notification of a Child Death
  4. Appendix 2: Form B - Agency Report Form
  5. Appendix 3: Form C - Analysis Pro-forma

1. Child Death Overview Panel

The Child Death Overview Panels (CDOP) will use the collective findings to take action to prevent deaths and improve the health and safety of all children in our communities, in accordance with the requirements of Working Together (2015) and Local Safeguarding Children Board regulation 6.

The purpose of the CDOP is to ensure that through a process of multidisciplinary review of child deaths, the Nottinghamshire and Nottingham City Safeguarding Children Boards will better understand how and why children in the local authority areas die. Terms of reference set out the role of the CDOP, membership and administrative arrangements.

For NSCB/NCSCB CDOPs, the primary functions are interpreted as being:

  • To review all deaths of children normally resident within Nottinghamshire and Nottingham City;
  • To gain an overview deaths of children not normally resident in Nottinghamshire and Nottingham City but who die within the County/City boundaries;
  • To quality assure the Rapid Response Process in relation to unexpected deaths of children;
  • To consider the need to make a referral into the Serious Case Review process;
  • To identify modifiable factors that may have contributed to the child's death and identify any support needs;
  • To collect and collate an agreed minimum data set of information on all deaths of children normally resident in Nottinghamshire and Nottingham City. This will include deaths that occur abroad and in other local authorities;
  • To evaluate data on the deaths of all children normally resident in Nottinghamshire and Nottingham City, thereby identifying lessons to be learned or issues of concern, with a particular focus on effective inter-agency working to safeguard and promote the welfare of children;
  • To identify significant risk factors and trends in individual child deaths and overall patterns of child deaths in Nottinghamshire and Nottingham City. This will include relevant environmental, social, health, cultural and service provision aspects of each death and any systematic or structural factors affecting children's well being to ensure a thorough consideration of how such deaths might be prevented in the future;
  • To identify any public health issues and consider, with the Directors of Public Health, commissioning bodies and other provided services how best to address these and their implications for both provision of services and for training;
  • To inform work aimed at increasing public awareness of issues that affect the health and safety of children.

In addition the child death review process should ensure that the Police and Children's Social Care are informed where concerns of a criminal or child protection nature come to light and also identify cases that may meet the criteria for a Serious Case Review (SCR).

Disseminating Lessons Learned

A key function of the CDOP is to ensure that lessons are learned from the child death review process. The Safeguarding Children Boards (SCBs) should use the aggregated findings from all child deaths to inform local strategic planning on how best to safeguard and promote the welfare of the children in their area. Key actions and evaluations will be included in the CDOP Annual Report which will be submitted to the SCBs. Public and professional awareness raising campaigns will be commissioned by the CDOP in conjunction with the relevant SCB sub groups.

Core Function of the Child Death Overview Panel

The CDOPs will receive notification of the deaths of all children from birth to 18 years in their respective areas. Foetal deaths in utero will not be considered by the CDOP nor will planned terminations of pregnancy carried out under the Abortion Act 1967. The death of any child whose birth has been registered should be notified to the CDOP.

Each CDOP will have a Child Death Function administrator by whom all notifications will be received.

Staff across all health communities will report the fact of all child deaths to their respective Designated Paediatrician of Unexpected Deaths (DPUD) or nominee. The Nottingham University Hospitals Trust and Sherwood Forest Hospitals Trust have child death review teams that receive notifications on behalf of the DPUD. The DPUD will ensure that Appendix 1: Form A - Notification of a Child Death, is completed and forwarded to the relevant CDOP administrator as soon as possible and in any case within two working days of the child's death. (For children dying outside of Nottinghamshire and Nottingham City, within two working days of being made aware of the child's death).

It is essential that the DPUD or nominee makes clear in this notification whether the case is being treated as an expected or unexpected death.

Where an unexpected death has been notified, the CDOP administrator will advise the relevant SCB Manager / Head of Safeguarding (children and young people's services) of the fact.

Where a child dies within Nottinghamshire/ Nottingham City but outside of their home health area the DPUD covering the area where the child died will ensure that the DPUD covering the child's home address is informed and that the relevant CDOP administrator is notified via Appendix 1: Form A - Notification of a Child Death.

The relevant DPUD should also notify the CDOP administrator of children from other Authorities who die within Nottinghamshire and Nottingham City. The CDOP administrator will relay this information to the CDOP covering the child's home area.

In these situations, it should be decided on a case by case basis which CDOP will take responsibility for reviewing the child's death although it is generally the case that the SCB for the area in which the child was normally resident at the time of death should take lead responsibility for conducting the review.

Nottinghamshire/Nottingham City Public Health will supply information provided by the Office of National Statistics (ONS), on a six monthly basis, to the County and City CDOP administrators. This will be used to check databases to ensure all deaths have been notified as required. (N.B. a record of Bassetlaw deaths will be maintained within the database held by the County PCT DPUD).

Information will also be supplied by the Coroner to the respective CDOPs in relation to any child death where an inquest is to be held or a post mortem examination is to be made under section 19 of the Coroners Act 1988. This information will be supplied using the agreed notification Form and within three working days of the decision to hold an Inquest or request a post-mortem.

The local Registrar of Births, Deaths, Marriages and Civil Partnerships will inform the relevant SCB of child deaths registered within 7 days of registration in accordance with the Children and Young Persons Act 2008.

Section 32 of the Children and Young Persons Act 2008 gives the Registrar General the 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. In such cases the CDOP will utilise other resources such as professional contacts or the media to source information in respect of the death of a child who is normally resident in the SCB area.

Where a child dies unexpectedly and healthcare management failures are suspected a Serious Incident Investigation (SI) is undertaken by the registered providers of Healthcare Services. The investigation is notified to, and monitored by, both the Lead Commissioners and the Care Quality Commission as set out in Regulation 6 of the Care Quality Commission (registration) Regulations 2009. The National Framework for Reporting and Learning from Serious Incidents requiring investigation provides further guidance about this process. The Serious Incident Investigation Report should be made available to the CDOP in order to allow the information to be included in the Panel's discussions.

The Youth Justice Board for England and Wales requires Youth Offending Teams (YOT) 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 (LMR) undertaken by the YOT should feed into the child death review undertaken by the CDOP. Where an LMR is about to be undertaken the YOT will notify the relevant SCB manager and Head of Safeguarding (children and young people's services) who, in turn, will ensure that the Child Death Administrator/Coordinator is aware. A representative from the YOT will then be invited to attend the CDOP to relay the findings of the LMR.

For all deaths the relevant DPUD with support from Lead Nurse will initiate completion of Appendix 2: Form B - Agency Report Form in conjunction with the responsible Consultant.

Unexpected Deaths; Following full implementation of the rapid response procedures, the DPUD with support from the Lead Nurse will complete and submit completed Appendix 2: Form B - Agency Report Form and proposed Appendix 3: Form C - Analysis Pro-forma following completion of the Rapid Response process.

Expected Deaths; Form B will be submitted by the DPUD with support from the Lead Nurse to the CDOP Administrator as soon as possible following its completion. The CDOP Administrator/Coordinator will ensure that the SCB manager ensures that relevant information is obtained from other agencies prior to the case being taken to the CDOP meeting for consideration.

The CDOP will consider the anonymised Form B (using a unique identifier but no identifiable information) and proposed Appendix 3: Form C - Analysis Pro-forma, which they will agree and complete. This will include categorising the child's death, determining its preventability and identifying any learning points and recommendations to be taken forward.

In cases of unexpected deaths, the CDOP will amend and/or ratify the proposed Appendix 3: Form C - Analysis Pro-forma arising from the Rapid Response processes.

Preventable deaths are 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 deaths.

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.

The decision regarding preventability cannot be finalised however until the outcome of other ongoing investigations is known, such as Serious Case Reviews, Serious Incident Investigations, criminal proceedings, post mortem or inquests.

Transfer of Information / Information Sharing

All information about the circumstances of the child's death, the child and the wider family will be protectively marked 'CONFIDENTIAL - CDOP' and should not be disclosed to anyone outside the child death review process in each respective SCB area. The dissemination of aggregated non personal data is permitted subject to approval from the relevant CDOP. Both the County and City CDOPs will have a single point of contact for all agencies via the CDOP administrators.

The transfer of personal or sensitive information as part of the CDOP processes referred to in this chapter should be via secure email (.gcsx, .pnn, .nhs.net, .cjsm). Any attachments should be password protected. All hard copy documents created, including minutes, should be securely stored and protected by two barriers e.g. in a secure cabinet within a secure building. Electronic data should be stored only on approved secure networks that are used by the agency in question to hold personal information and where access is controlled appropriately. Portable media devices (e.g. data sticks) should not be used for the permanent storage of CDOP related information. Where it is necessary to use such a device on a temporary basis it should be approved and encrypted. The CDOP administrator/coordinator will maintain a database and copies of all forms reflecting the information gathered, these records will be retained in line with the respective Local Authorities Records Management Policies. CDOP members are responsible for securely disposing of information obtained from other agencies during the course of a review once that review is completed.

Media interest in the work of CDOPs or in individual cases will be dealt with by the relevant authority's Press Officer in consultation with the SCB Manager.

The Annual Report of CDOPs will be a public document and as such will have no identifiable information contained within. Details of individual case discussions are to be kept confidential and in no circumstances will such details be passed to the press.

Parental Engagement in the Child Death Review Process

Parents and family members should be informed that their child's death will be reviewed, and that they may have significant information and questions to contribute to the review process. This process may require the use of interpreters, communication aids or other means to ensure full participation and consultation. All parents will be provided with literature that explains the review process by the Rapid Response Doctor for deaths that are unexpected and within the bereavement information pack given by Health colleagues for deaths that are expected.

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.

Child Protection Concerns

If, during Child Death Review processes, concerns arise in relation to the needs of any identified children, discussions should take place with the appropriate Children's Social Care Team.

Where concerns of a criminal or Child Protection nature come to light that have not previously been identified (or apparently new information relating to a previous or current enquiry), the Chair of the CDOP will ensure that the Police and Children's Social Care are informed so that action can be taken as appropriate. Where information is identified that may indicate that the criteria for a SCR may have been met, but no referral has yet been made, this should be discussed with the Chair of the relevant SCR Standing Panel.

Cross Authority CDOPs

The cross Authority CDOP meetings will:

  • Consider collated, aggregated information relating to all child deaths in Nottinghamshire and Nottingham City;
  • Identify and consider patterns or trends within this information;
  • Make recommendations for action to address identified areas of concern, referring these to the appropriate agency or LSCB for consideration;
  • Through panel representatives, meet with the Coroner on a six monthly basis to discuss the findings and proposals of the panel;
  • Contribute to an annual report to both SCBs.

Each CDOP will provide the relevant SCB and its constituent agencies with an annual report on the work of the panel. This report will contain the single and cross authority findings in relation to deaths of children.

The NSCB and NCSCB will take responsibility for disseminating the lessons to be learned from CDOP activity to all relevant organisations, ensuring that relevant findings inform the Children and Young People's Plans and SCB business plans.

Click here for Figure 1: Child Death Review Process.

Click here for Figure 2: Rapid Response Process.

2. Rapid Response to Unexpected Child Deaths

Definition

For the purposes of this procedure 'unexpected deaths' of children and young people are defined as "the death of an infant or child (less than 18 years old) which:

  • Was not anticipated as a significant possibility for example, 24hrs before the death; or
  • Where there was a similarly unexpected collapse or incident leading to or precipitating the events which led to the death" (Working Together 2015).

The on call UD (unexpected death) Paediatrician should be consulted where professionals are uncertain as to whether or not a death falls within this definition. If in doubt, the processes for unexpected deaths should be followed until the available evidence enables a different decision to be made.

Deaths of Newborn Babies in Hospital

If a baby dies within 24 hours of birth or shortly thereafter due to an event related to the birth whilst under medical supervision, and there is a clear medical explanation for the death, this should not be treated as an unexpected death.

If a baby dies within 24 hours of birth in the same circumstances (i.e. whilst under medical supervision), with no immediate medical explanation apparent for the child's death, the situation should be discussed with the on call UD Paediatrician. The on call UD Paediatrician will make a decision (informed by the circumstances surrounding the death and information available to them within Health) as to whether the case should be regarded as an unexpected death and so fall within these procedures.

Introduction

These procedures apply to all agencies following all incidents of unexpected deaths of children and young people under 18 years. Clearly the death of a child is extremely distressing for parents, and families. Throughout this process the support needs of parents should be adequately and appropriately addressed by all agencies.

The purpose of this procedure is to ensure an early multi-agency response to all unexpected deaths of children in order to:

  • Understand the reasons for the child's death;
  • Address the possible needs of other children in the household and of all family members;
  • Identify those deaths that may be as a result of abuse or neglect and ensure an appropriate response;
  • Consider any lessons to be learnt about how best to safeguard and promote the welfare of children in the future including consideration of any wider public health implications.

The revised procedure sets out a structure within which reasoned judgements can be made when evaluating an unexpected child death on the basis of all available information. It is important therefore that all staff remain open minded when considering any death and avoid reaching conclusions inappropriately outside of the agreed processes.

To support this function the rapid response is provided by Designated Paediatricians for Unexpected Deaths (DPUD) and on call UD Paediatricians in conjunction with representatives from the Police and Children's Social Care.

Where Children's Social Care and the Police are referred to, unless otherwise specified, this means Children's Social Care and the Police covering the area in which the event leading to the child's death occurred.

The DPUD role is supported by a small team of Specialist Nurses who may carry out a range of functions ascribed to the UD Paediatrician role within this guidance. This will be done under the supervision of the DPUD or other Consultant Paediatrician when the DPUD is not available. References to the UD Paediatrician in this document can be taken to include a Specialist Nurse other than in the chairing of the final case discussion meeting which will remain a role for the DPUD or delegated Paediatrician.

In principle it is recognised that all information relevant to the enquiry should be shared by all agencies. The Police, however, may consider certain information sub judice or subject to continuing investigation and this may preclude it being released in an open forum, especially where the parents may be present. In these cases they should ensure that the information is shared with colleagues in other agencies in an appropriate and timely manner. Any decision not to share information should be recorded by the Senior Investigating Officer (SIO) in their Police log.

Immediate Action following an Unexpected Death

Where a child dies unexpectedly in the community the child should in almost all circumstances be taken to a Hospital Emergency Department. However, the timing of this will depend upon the circumstances of the child's death.

Wherever there are immediate concerns as to the circumstances of the child's death the Police retain primacy for the crime scene and will need to carry out a forensic examination. The Police will discuss with the Coroner and Home Office Pathologist arrangements for examination and removal of the body.

Where the child has been pronounced dead at the scene or is 'obviously dead' then there may be a delay in the removal of the body to the Emergency Department pending forensic examination. In these circumstances a protocol has been agreed with the East Midlands Ambulance Service that an ambulance will return to the scene to transport the child's body to the Emergency Department at the authorisation of the police.

Very occasionally it may not be seen as appropriate to remove the child's body to the Hospital Emergency Department (e.g. where the body is in an advanced stage of decomposition). In such circumstances the appropriate course of action should be agreed between the SIO from the police and the on call UD Paediatrician.

Once the child has been pronounced dead in Hospital (or the death has been confirmed) the responsible Consultant Paediatrician will inform the parents of the death and explain the process of the multi-agency response to all unexpected child deaths. Form 1, 'Emergency Department' (unexpected child deaths), should be completed in the Emergency Department (ED) by a member of the ED Team. It is the responsibility of the hospital consultant to share this information with the on call UD Paediatrician and ensure all other relevant professionals have been informed of the death. This will include the Coroner, the local Divisional Police and Children's Social Care covering the area where the event leading to death occurred. For young people of 16 and 17 years old this may be a Consultant responsible for the child's care other than a Paediatrician. A member of the Hospital staff should be allocated to the family for ongoing support whilst at hospital.

Where the death occurs outside of usual office hours the Emergency Duty Team (EDT) of the appropriate Children's Social Care department needs to be contacted by the responsible Consultant Paediatrician. The EDT is responsible for checking whether the child and family are known to them and engaging in initial discussions with key staff and handover to the day time teams.

Having been made aware of the child's death, the on call UD Paediatrician with support from the Lead Nurse will check that all relevant professionals have been informed of the death (as above), and will share information with the wider group e.g. the health visitor, midwife, Designated/Consultant Nurse, School Nurse, G.P. and other specialist health workers involved in the child's care. Planning discussions will take place between staff at an operational level in the lead agencies i.e. Health, Police (SIO) and Children's Social Care (team manager) to decide what should happen next and who will do what. The Coroner and other relevant persons or agencies, including the Fire Investigation Team if the death has been caused by fire, must also be contacted. The agreed outcome of these discussions will be recorded by the on call UD paediatrician on Form 3, 'Record of Interagency Discussion' (unexpected child deaths).

On receipt of this information the Children's Social Care team manager should immediately inform their Service Manager or the on call senior manager if out of hours, who in turn will inform the respective Head of Service for Fieldwork and Head of Service for Safeguarding and Independent Review/Quality Assurance.

Initial Case Discussion Meeting

The level and type of communication following the unexpected death of a child will depend on the circumstances of each case. In the majority of cases this will include an Initial Case Discussion Meeting convened by the UD Paediatrician who will be responsible for ensuring that representatives from relevant agencies are invited to attend. This should be held within 3 working days where possible. The meeting will follow the agenda set out in the Initial Case Discussion Meeting Agenda and will be minuted by the Health Child Death Review Team administrator. Minutes from this meeting should be circulated within 10 working days.

In a few cases an Initial Case Discussion Meeting may not be necessary. It is the responsibility of the UD Paediatrician to liaise with other lead agencies to make a joint decision not to hold an Initial Case whether the cause of death is fully explained:

  • Whether there are any gaps in the information;
  • Whether there are any concerns identified;
  • Whether a coordinated package of support for the family is in place.

It should be noted that in all cases a Final Case Discussion Meeting is required.

Where the child who has died, or a child in the same household is an open case to Children's Social Care the function of the Initial Case Discussion Meeting will be carried out within a Strategy Meeting (see Strategy Meeting below). This will be chaired by the Child Protection Coordinator (CPC) in the County and by the Principal Manager or / Independent Reviewing Officer (IRO) for the city. Professional judgement will need to be used when deciding the most appropriate agency to lead the Initial Case Discussion Meeting. Where children who have life limiting conditions die unexpectedly see Sudden Unexpected Deaths in Children & Young People with Life Limiting Conditions below for further guidance.

The Strategy Meeting should take place within 24hrs where practically possible, and in any event within 48 hours. This does not prevent strategy discussions taking place between the parties in the interim, especially where there is a need to consider the immediate safety of siblings; the on call UD Paediatrician should be invited. The CPC/IRO will also be responsible for co-ordinating the Final Case Discussion Meeting when all enquiries are complete. Where there have been previous concerns regarding the child and/or family or where there are concerns surrounding the circumstances of the child's death the Pathologist should be engaged at an early stage and invited to the Initial Case Discussion Meeting/Strategy Meeting.

All Cases of Unexpected Deaths

Children's Social Care should make enquiries such that relevant background information in relation to the child that has died and any siblings is obtained from all Children's Services with the Local Authority e.g. MALT, Youth Offending Team, Education, Youth Service and Children's Centres.

The Police have a responsibility to investigate all unexpected deaths of children on behalf of the Coroner. The role of the on call UD Paediatrician at this stage is to ensure all activity between agencies is carried out in a co-ordinated fashion.

Where there are immediate concerns that abuse or neglect has been a factor in the child's death, the case will be subject of a joint investigation involving the Police and Children's Social Care from the outset. In these circumstances Children's Social Care have the responsibility for co-ordinating the overall safeguarding investigation as laid out in Child Protection Enquiries Procedures of these procedures and the police have responsibility for coordinating any criminal investigation. The function of the Initial Case Discussion Meeting will be incorporated into these processes.

Abuse or Neglect Known or suspected to be a Factor in a Child's Death

At any stage throughout this process, where concerns emerge that abuse or neglect have been a factor in the child's death, joint investigations will be undertaken. The Police will take the lead in the criminal investigation and Children's Social Care will take the lead for co-ordinating inter-agency activity, and information sharing. Input from Health colleagues will be co-ordinated by the on call UD Paediatrician. The on call UD Paediatrician should be seen as central to discussions and be invited to any meetings convened.

Children's Social Care should initiate S47 Enquiries following the strategy discussion and the procedures outlined in, Child Protection Enquiries Procedures followed. A Strategy Meeting will be convened within 24 hours of the decision being made. The Strategy Meeting will be chaired by the CPC/IRO and consideration given to the convening of an Initial Child Protection Conference.

The circumstances of these cases will also be likely to meet the criteria for a Serious Case Review as outlined in Serious Case Reviews and the procedure in that section should also be followed.

Strategy Meeting

The agenda for the Strategy Meeting is outlined in Child Protection Enquiries Procedure, Strategy Discussion/ Meeting and the following specific considerations should be included:

  • Establish whether any concerns are indicated by any initial views about the cause of death;
  • Establish whether there is any relevant background information to indicate the need for further enquiries;
  • Agree what further enquiries will be undertaken and by whom;
  • Consider whether S47 Enquiries should be continued;
  • Agree how and when parents should be notified of the enquiries;
  • Focus on any surviving or unborn siblings as well as the child who has died;
  • Use of the Initial Case Discussion agenda, invites and information sheet for attendees.

The SIO from the Police should ensure that the Coroner's Office is informed of the outcome of the Strategy Meeting and any subsequent Strategy Meetings needing to be held. Upon receipt of the final post mortem results it will be the responsibility of the CPC/IRO to coordinate a Final Case Discussion Meeting whether or not this meeting falls outside of the Child Protection Procedures. Additionally, the final post mortem results and ongoing investigation may provide further information indicating the need for a further Strategy Meeting.

Home Visit

When a child dies unexpectedly in a non hospital setting, the Police SIO and the on call UD Paediatrician should make a decision about whether a visit including the on call UD Paediatrician should be made to the place where the child died. This should almost always take place for children under 2 years who die unexpectedly (Working Together 2015) but should be considered in all cases. Where agreed, this visit should take place within 24 hours after the child's death and in most circumstances be a joint visit between the Police and the on call UD Paediatrician. Information from this visit will be recorded by the on call UD paediatrician on Form 2 the 'Record of Home Visit' (unexpected child deaths).

After this visit the on call UD Paediatrician will facilitate a discussion with the Police (SIO), Children's Social Care representative (team manager) along with other relevant professionals to review any information obtained from the visit that could raise concerns about the possibility of abuse or neglect contributing to the child's death. This can take the form of a telephone discussion or meeting dependent on the circumstances of the case. If such concerns arise, then the case should be investigated as laid out in Child Protection Enquiries Procedures of these procedures. The outcome of these discussions will be recorded by the on call UD paediatrician on the Form 3, 'Record of Interagency Discussion' (unexpected child deaths).

In all cases the police will complete an Initial Coroner's Report, containing copies of Forms 1 and 2 (ED and Home Visit Forms), at the earliest opportunity and within a maximum of 24 hours. This report should be agreed between the on call UD Paediatrician and the SIO and reflect multi agency discussions thus far.

Sudden Unexpected Deaths in Hospital

Unexpected deaths/collapse leading to death also occur on Hospital wards. Such deaths can occur in any setting where children are cared for. The response to these deaths needs to be as rigorous as any deaths occurring in the community but may be modified depending on the circumstances. The UD Paediatrician will work closely with the responsible consultant to manage the response to the child's death.

The Consultant on call for acute paediatrics/neonates should attend to help coordinate the response and support the family and staff. The Coroner should be informed as soon as possible within working hours or immediately if there are concerns that the death may be suspicious. Nursing and Medical staff who were on shift when the infant/child died should document what happened before the end of their shift on Form 1.

The UD Paediatrician should be informed as soon as practical (on call from 7am-7pm). The UD Paediatrician will take a detailed history of the events leading up to the collapse/death using Form 2. It is the responsibility of the UD Paediatrician to coordinate the multi-agency information sharing.

Children's Social Care should be informed about the death. There should be a discussion with the Police (in their role as Coroner's Officers) as to whether they need to visit the ward (similar to the joint home visit in community cases). Where there are no specific concerns this may not be necessary. If the Police feel a joint visit is necessary, consideration needs to be given as to whether both staff and parents are present for this. There will need to be explicit discussion about what can be shared with parents and who will do this at each stage.

Concerns may be raised for example where there is suspicion that equipment may have been tampered with, unusual behaviour by family members or staff or when serious Child Protection concerns have already been identified. Until this has been clarified the cot/bed where the infant died should be left undisturbed. If this is not possible (e.g. the child was on an open ward) the cot/bed clothes should be kept separately until the UD Paediatrician and Police give further instructions. Fluids, syringes, drugs and other nursing or feeding equipment used should not be discarded until the decision about the Police visit has been clarified.

An Initial Case Discussion Meeting chaired by the UD Paediatrician will always be convened in these circumstances unless a Strategy Meeting is convened in its place under the criteria described earlier. In some cases the preliminary results of the post mortem will be known. There should be representation at this meeting by Police, Health and Children's Social Care. During this meeting there should be explicit discussion about the possibility of neglect or deliberate injury contributing to the child's death either by parents or staff. Consideration should be given to inviting representatives from the Trust Clinical Governance Team (CGT). In all cases the minutes should be provided to the CGT.

The Paediatrician responsible for the child's care should also attend this meeting to provide factual information of the events leading to the collapse/death. The UD Paediatrician and Consultant responsible will need to consider whether the case needs further internal investigation via the Serious Untoward Incident (SUI) process. If a SUI is thought to be appropriate an incident form should be completed and a copy should be provided with the minutes to the CGT. This is a separate process to the Rapid Response and Child Death Review process although one may inform the other. Multi agency case discussion meetings should be minuted as outlined.

There should also be a discussion as to who would be the most appropriate person to support the family after the death and share information with them regarding the post mortem and further investigations.

Sudden Unexpected Deaths in Children & Young People with Life Limiting Conditions

Children with recognised life limiting conditions are usually cared for by a multi-agency team led by a Paediatrician. Some of these will have a documented Personal Resuscitation Plan (PRP) which will have been shared with all agencies involved. The death of these children may not be anticipated 24 hours before. However, many children who are at risk of rapid deterioration or sudden death do not have a formal PRP in place even though their death may be anticipated. The response to all these deaths needs to be as rigorous as any other unexpected deaths but may be modified depending on the circumstances. The UD Paediatrician will work closely with the responsible Consultant to manage the response to the child's death.

The child will be brought to the Emergency Department unless there is a documented PRP stating otherwise. The Consultant on-call for acute paediatrics should attend to help coordinate the response. The Paediatrician usually caring for the child should be contacted as soon as possible (usually in working hours) and the DPUD should also be contacted. The Coroner should be informed as soon as possible within working hours or immediately if there are concerns that the death may be suspicious.

The UD Paediatrician should be informed as soon as practical (on call from 7am-7pm). The UD Paediatrician should work closely with the Paediatrician responsible for the child who will have detailed knowledge of the medical and social issues for the child. Children's Social Care should be informed about the death. There should be a discussion with the Police (in their role as Coroner's Officers) as to whether they need to visit the place where the child collapsed / died. Children with complex problems are more likely to be cared for in a number of environments and death may not necessarily occur at home. Where there are no specific concerns, this may not be necessary. If the Police feel a joint visit is necessary, consideration needs to be given as to whether carers and or parents are present for this.

Following these discussions it may be possible to reclassify the death as "expected". Where there is some concern about the exact nature of the death or underlying concerns have been identified, the death should be treated as unexpected and an Initial Case Discussion Meeting convened as below. It is the responsibility of the UD Paediatrician to coordinate the multi-agency information sharing in the event that the death is unexpected.

An Initial Case Discussion Meeting will always be held in these circumstances. In some cases the preliminary results of the post mortem will be known. This meeting will usually be chaired by the UD Paediatrician. The child is likely to be known to Children's Social Care due to their disability. There should be representation at this meeting by Police, Health and Children's Social Care. During this meeting there should be explicit discussion about the possibility of neglect or deliberate injury contributing to the child's death either by parents or other carers. The paediatrician responsible for the child's care should also attend this meeting to provide factual information of the events leading to the collapse/death.

Post Mortem

In almost all cases of an unexpected child death the Coroner will order a post mortem examination to be carried out. The on call UD Paediatrician should share the information collated thus far and pass copies of Forms 1,2 (ED and Home Visit Forms) and other relevant information to the Pathologist conducting this post mortem in order to inform this process. Where a Home Office Pathologist is to conduct the post mortem this information will be passed via the Police SIO.

Preliminary Post Mortem Results

The preliminary results of the post mortem examination (in most circumstances) should be discussed between the on call UD Paediatrician, Pathologist and the Police SIO as soon as possible. The Coroner should be informed immediately of the initial results. This will be the responsibility of the Pathologist.

In all cases the on call UD Paediatrician should initiate a further multi agency discussion as soon as possible after the initial post mortem results are available, and, other than in exceptional circumstances, within 5 days after the child's death. This should involve the Pathologist, Police, Children's Social Care, the on call UD Paediatrician plus any other relevant professionals. This discussion will review any further information that has come to light and that may raise additional concerns about safeguarding issues. Where concerns regarding the history of the family, or circumstances of the death are emerging (but below the threshold for s47 enquiries), a face to face multi-agency meeting should be convened by the on call UD Paediatrician to facilitate these discussions. The discussion/meeting will be recorded by the on call UD paediatrician.

The Coroner should be informed of any relevant new information coming to light as a result of these considerations. This will be the responsibility of the Police SIO.

Final Case Discussion Meeting

The on call UD Paediatrician (or CPC / Principal Manager / IRO* where a Strategy Meeting has been held in place of an Initial Case Discussion) should convene and chair a meeting immediately after investigations into the death are complete. If it has been agreed that there are no ongoing concerns for any children in the family, the final case discussion meeting can be chaired by health. This agreement should be reached between the on call paediatrician and the manager of the case within social care in liaison with the CPC/IRO who chaired the initial meeting. The meeting should include the final post mortem results and the outcome of any police investigation. Ordinarily the meeting should be convened within 3 months however the timing will vary according to the circumstances of the child's death. The meeting should involve those who knew the child and family and those involved in investigating the death. e.g. G.P., Health Visitor, School Nurse, Paediatrician, Pathologist, Police SIO and Children's Social Care. If updated information is held by Police or Children's Social Care representatives must attend the meeting.

Purpose of the Final Case Discussion Meeting

The agenda for the Final Case Discussion Meeting should be followed. The purpose of this meeting is to:

  • Provide a summary of the circumstances leading to the child's death;
  • Update information to assist the identification of the cause of death and contributory factors;
  • To provide analysis of the child's death with reference to the domains on Appendix 3: Form C - Analysis Pro-forma;
  • To consider learning points and recommendations and to determine plans for future care of the family.

There should be an explicit discussion of the possibility of abuse or neglect either causing or contributing to the child's death. Where there is no evidence identified to suggest ill treatment, this should be documented as part of the minutes of the meeting. It should also be agreed how detailed information about the cause of the child's death will be shared, including with the parents.

Where new information comes to light to suggest abuse or neglect may be a factor in the child's death, the case should be managed as described above.

A record of the meeting should be made and a provisional Appendix 3: Form C - Analysis Pro-forma should be drafted for discussion and ratification at the Child Death Overview Panel. This should be circulated for agreement and once agreed be included within the file prepared by the SIO for the Coroner and be taken into consideration in the conduct of the inquest.

Appendices

Appendix 1: Form A - Notification of a Child Death

Appendix 2: Form B - Agency Report Form

Appendix 3: Form C - Analysis Pro-forma