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London Safeguarding Children Board: Child Protection Procedures 5th Edition London SCB Powered by tri.x Powered by tri.x
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9. Unexpected Death of a Child

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Contents

9.1

The death of a child

 

9.1.1

Introduction

 

9.1.2

The Regulations relating to child deaths

 

9.1.3

Children with life limiting or life threatening conditions

 

9.1.6

Involvement of parents and family

9.2

Local framework for responding to child deaths

 

9.2.2

Designated paediatrician for child deaths

 

9.2.4

Designated person (DP)

 

9.2.9

Notification of a child death

9.3

Child death overview panel (CDOP)

 

9.3.4

Partner agency representation and responsibility

 

9.3.10

Frequency of CDOP

 

9.3.12

Key functions

 

9.3.13

Deaths of children out of area

 

9.3.19

Consent and confidentiality

 

9.3.25

Learning from child deaths

 

9.3.28

Reporting mechanisms

9.4

Information sharing in relation to child deaths

 

9.4.4

Duty and powers of coroners to share information

 

9.4.6

Duty and powers of medical examiners (MEs) to share information

 

9.4.7

Definition of a preventable child death

 

9.4.9

Use of child death information to prevent future deaths

9.5

Rapid response service for unexpected child deaths

 

9.5.1

Definition of an unexpected child death

 

9.5.3

Rapid response remit

 

9.5.9

Rapid response timetable

9.6

Other related processes


9.1

The death of a child

 

Introduction

9.1.1

This chapter sets out the processes to be followed when a child dies in the Local Safeguarding Children Board area/s covered by a Child Death Overview Panel. There are two inter-related processes for reviewing child deaths (either of which can trigger a serious case review, see Serious Case Reviews Procedure):

  • Rapid response by a group of key professionals coming together for the purpose of enquiring into and evaluating each unexpected death of a child; and
  • 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 Local Safeguarding Children Board area/s, undertaken by a Child Death Overview panel.

    (Reviews of deaths which follow a planned termination under the law (Abortion Act 1967) should not be carried out by Child Death Overview Panels even in instances where a death certificate has been issued. If the Local Safeguarding Children Board has general concerns about local procedures relating to planned terminations, it should contact the Care Quality Commission (enquiries@cqc.org.uk). All other deaths (i.e. excluding those deaths which follow a planned termination of pregnancy under the law) which have been registered as live with the General Registrar's Office, should be reviewed by the Child Death Overview Panel.)


The Regulations relating to child deaths

9.1.2

One of the Local Safeguarding Children Board 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:

  1. Collecting and analysing information about each death with a view to identifying -
    1. Any case giving rise to the need for a review mentioned in Regulation 5(1)(e);
    2. Any matters of concern affecting the safety and welfare of children in the area of the authority; and
    3. Any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area; and
  2. Putting in place procedures for ensuring that there is a co-ordinated response by the authority, their Board partners and other relevant persons to an unexpected death.
  3. The responsibility for determining the cause of death rests with the coroner or the doctor who signs the medical certificate of the cause of death (and therefore is not the responsibility of the Child Death Overview Panel (CDOP)).
  4. In reviewing the death of each child, the CDOP should consider modifiable factors, for example, in the family 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.

Definition of preventable child deaths:

9.1.3

For the purpose of producing aggregate national data, Working Together to Safeguard Children 2015 defines preventable child deaths as those in which modifiable factors may have contributed to the death. These are factors defined as those, where, if actions could be taken through national or local interventions, the risk of future child deaths could be reduced.


Children with life limiting or life threatening conditions

9.1.4

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.

9.1.5

Professionals responding to the death of a child with a LL/LT condition should ensure that their response to the families concerned is appropriate and supportive and does not cause any unnecessary distress. End of life care plans may be in place and where appropriate, families should be supported to choose where their child's body is cared for after death e.g. a children's hospice.

9.1.6

The unexpected, death of a child with LL/LT condition should be managed as for any other unexpected death so as to determine the cause of death and any contributory factors.


Involvement of parents and family members (for all child deaths)

9.1.7

Local Safeguarding Children Boards must have mechanisms in place for appropriately informing and involving parents and other family members in both the child death overview and the rapid response processes.

9.1.8

Parents should be advised that the child's death will be subject to a review in order to learn any lessons in order to improve the health, safety and well being of children with a view to preventing further such child deaths where possible. It should be emphasised that the process is not about culpability or blame. This would normally be done by the designated paediatrician confirming the child's death to the parents.

9.1.9

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 with a view to preventing further such child deaths where possible. The process is not about culpability or blame.

9.1.10

The Local Safeguarding Children Board, acting through the child death overview panel 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 what information is shared, with whom, and why must be recorded in each agency's records. It is not appropriate for parents to attend the child death overview panel 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.

9.1.11

Parents should be informed that all cases will be anonymised prior to discussion by the child death overview panel, 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 child death overview panel will make recommendations and report on the lessons learned to the Local Safeguarding Children Board. The Local Safeguarding Children Board 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.

9.1.12

Child death overview panels should ensure that whenever necessary, arrangements are made for the family to have the opportunity to meet with relevant professionals, e.g. a professional known to the family before their child died a paediatrician or a police officer to help answer their questions.

9.1.13

Child death overview panels should review the services and immediate support offered to families of children who have died (see information around care of the bereaved family in the (see Key strands of rapid response).


9.2

Local framework for responding to child deaths

 

9.2.1

The framework which each Local Safeguarding Children Board should have in place for responding to child deaths should include:

  • A designated paediatrician for child death;
  • A single point of contact to be informed of all child deaths;
  • A child death overview panel (see Child death overview panel);
  • An working relationship with the local coroner's office; and
  • A rapid response team. The Local Safeguarding Children Board should assure itself that Board partners have adequate local arrangements for responsible on-call professionals with relevant expertise to function as a multi-agency rapid response service to the unexpected death of a child (see Key strands of rapid response);
  • The CDOP should include a professional from public health as well as child health.


Designated paediatrician for child death

9.2.2

Each CCG should ensure that the Local Safeguarding Children Board, through the child death overview panel, has access to a consultant paediatrician whose designated role is to provide advice on:

  • The commissioning of paediatric services from paediatricians with expertise in undertaking enquiries into unexpected deaths in childhood and the medical investigative services such as radiology, laboratory and histopathology services; and
  • The organisation of such services.

The designated paediatrician for child death may provide advice to more than one CCG, and is likely to be a member of the local child death overview panel. 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.

9.2.3

The designated paediatrician or equivalent, is responsible for co-ordinating the multi-agency response to all child deaths in a Local Safeguarding Children Board area which are unexpected or where the cause of the death is uncertain.


Designated Person (DP)

9.2.4

In order for Local Safeguarding Children Boards (LSCBs) to fulfil their child death reviewing responsibilities, each 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 (DP) to whom the 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 Department of Education website). The Chair of the child death overview panel is responsible for ensuring that this process operates effectively.

9.2.5

The DP will also need be informed about the death of a child normally resident in the area but who has died elsewhere  and must inform the relevant other DP about a child death where the child normally resides elsewhere.

9.2.6

The Registrar has a duty to send a notification of each child's death to the DP. This should enable the DP to check that he or she has been notified of all child deaths in the area.

9.2.7

Any professional or member of the public hearing of a local child death in circumstances that mean it may not yet be known about, e.g. a death occurring abroad, can inform the designated person in the LSCB.

9.2.8

The details of each borough's DP must be reported to the London Safeguarding Children Board to enable a list to be kept up to date on the London SCB website.


Notification of a child death

9.2.9

National templates are available for Local Safeguarding Children Boards to use to assist collecting information about child deaths. For initial notification see the Local Child Death Contacts page on the website.

London will use the Forms B - E. All forms are available at National templates for LSCBs to use when collecting information about child deaths.


Notification process:

Responsibilities of all agencies 

9.2.10

Local agencies responding to a child's death should inform:

  • The coroner, within one working day as appropriate;
  • The DP; and
  • The designated paediatrician or equivalent, if the death is unexpected or the cause of death is uncertain.

The information can be conveyed to the designated paediatrician or equivalent, in a confidential telephone conversation. However, there must be agreement during this call as to who will take responsibility for completing the London child death initial notification form and sending it to the DP.

9.2.11

The police public protection desk has a key role in informing the designated paediatrician or equivalent, and/or the DP of child deaths.


9.3

Child death overview panel (CDOP)

 

9.3.1

The purpose of a child death overview panel is to undertake an overview of all child deaths within the locality. This process uses a standard set of data (see the Department of Education website) 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 such as:

  • Case summaries from health records;
  • Case information from police, LA children's social care and education; and
  • Post-mortem reports.

9.3.2

The CDOP has responsibility for reviewing the deaths of all children, with priority given to those deaths that are both unexpected and unexplained.

9.3.3

Where necessary, the CDOP has the authority to recommend that a serious case review should be undertaken by the Local Safeguarding Children Board. If there is to be a serious case review, it will be undertaken by the Local Safeguarding Children Board where the child normally resides, with the final decision taken by the Local Safeguarding Children Board Chair. See Serious Case Reviews Procedure.


Partner agency representation and responsibility

9.3.4

The CDOP should have a permanent core membership drawn from the key organisations represented on the Local Safeguarding Children Board. The minimum should be senior management representation from:

  • Designated paediatrician for unexpected deaths in childhood;
  • Public health;
  • Community child health or designated nurse for safeguarding children;
  • LA children's social care;
  • Police.

9.3.5

Other members should be co-opted as and when appropriate. This may be so that the membership of the CDOP better reflects the characteristics of the local population, to provide a perspective from the independent or voluntary sector or to contribute to the discussion of certain types of death (e.g. London Fire Brigade, adult mental health services, education / early years, bereavement services etc.

9.3.6

The CDOP Chair is accountable to the Local Safeguarding Children Board, but should not be involved in providing direct services to children and families in the Local Safeguarding Children Board area.

9.3.7

Within each organisation represented on the Local Safeguarding Children Board, a senior person with relevant expertise should be identified as the lead professional with responsibility for 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.

9.3.8

The CDOP should have a clear relationship and agreed channels of communication with the local coronial service.

9.3.9

The LSCB should ensure that appropriate single and inter-agency training is made available to ensure successful implementation of these processes. LSCB partner agencies should ensure that relevant staff have access to this training - (see 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.)


Frequency of CDOP meetings

9.3.10

The CDOP should hold meetings on a regular basis to enable the circumstances of each child death to be discussed in a timely manner. The frequency of the meetings should reflect the number of child deaths in the Local Safeguarding Children Board area.

9.3.11

The CDOP should ensure that all other processes (e.g. coronial enquiries, legal proceedings, serious case reviews etc) have concluded before reviewing a child death, although data collection should continue in the meantime.


Key functions

9.3.12

The key functions of the CDOP are to:

  • Receive notification on all child deaths occurring in the local area;
  • Collect and collate an agreed national minimum data set;
  • Seek information from professionals who had involvement with the child before and immediately following the death and, where relevant, the child's family members;
  • Discuss each child's case, and provide relevant information or any specific actions related to individual families to those professionals who are involved directly with the family so that they, in turn, can convey this information in a sensitive manner to the family;
  • Evaluate the data available and identify lessons to be learnt or issues of concern, with a particular focus on effective inter-agency working to safeguard and promote the welfare of children;
  • Determine whether the death was deemed preventable, that is, those deaths in which modifiable factors may have contributed to the death and decide what, if any, actions could be taken to prevent future such deaths;
  • Assess the cases with regard to the threshold criteria to enable specific cases to be reviewed in depth;
  • Ensure that individual case discussions have taken place regarding unexpected child deaths;
  • Monitor the appropriateness of the response of professionals to an unexpected death of a child, reviewing the reports produced by the rapid response team on each unexpected death of a child, making a full record of this discussion and providing the professionals with feedback on their work. Where there is an ongoing criminal investigation, the Crown Prosecution Service must be consulted as to what it is appropriate for the CDOP to consider and what actions it might take in order not to prejudice any criminal proceedings;
  • Scrutinise the recommendations from the reports compiled by the designated doctor for unexpected deaths;
  • Identify any common themes from individual cases and consider these in more depth (e.g. road traffic deaths, sudden unexpected death in infancy (SUDI), or deaths of children with life limiting conditions);
  • Consider whether the death was preventable, if so how such deaths might be prevented in the future;
  • Identify any patterns or trends in the local data and report these back to the Local Safeguarding Children Board;
  • Consider the Referral and Assessment Procedure to assess any child, parent and social or environmental factors, which could contribute to developing an understanding of the individual child's death;
  • Alert the Chair of the Local Safeguarding Children Board about any deaths where, on evaluating the available information, the CDOP considers there may be grounds to undertake further enquiries, investigations or a serious case review and explore why this had not previously been recognised;
  • Inform the Chair of the Local Safeguarding Children Board where specific new information should be passed to the coroner or other appropriate authorities;
  • Monitor the support and assessment services offered to families of children who have died;
  • Monitor and advise the Local Safeguarding Children Board on the resources and training required locally to ensure an effective inter-agency response to child deaths;
  • Identify any public health issues and consider, with the Director/s of Public Health, how best to address these and their implications for both the provision of services and for training;
  • Co-operate with regional and national initiatives to identify lessons on the prevention of unexpected child deaths e.g. the London learning from information about child deaths initiative and the 'MBRRACE-UK: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK' which is a national system;
  • Ensure each partner agency of the Local Safeguarding Children Board identifies a senior person with relevant expertise to have responsibility for advising on the implementation of the local procedures on responding to child deaths within their agency.


Deaths of children out of area

9.3.13

The CDOP in the area where the child was normally resident will review the death and liaise with the area where the child died, where appropriate. For children not normally resident in London, the CDOP Chair for the area where the child died should also write to the CDOP conducting the review to ensure that any lessons are shared across both areas. The CDOP Chair for the area where the child was normally resident is responsible for ensuring that this process operates effectively. To avoid unnecessary additional burden on professionals and the child's family, it is not recommended that the two Local Safeguarding Children Boards conduct individual reviews.

9.3.14

If it is unclear in which CDOP area the child normally resided (such as in cases of shared care arrangements in different boroughs), the relevant CDOP Chairs should negotiate and agree who will lead the review. If no agreement can be reached, the CDOP chairs involved should escalate the issue to their respective Local Safeguarding Children Boards, for agreement to be reached by the Local Safeguarding Children Board Chairs. Timescales should not be allowed to slip, therefore until any dispute is resolved, the case must be treated as the responsibility of the disputing LSCB in whose area the child was last known to have been alive (note: this point is currently subject to approval).

9.3.15

Information sharing between two CDOPs when a child dies out of his / her normal residency area is in addition to informing the coroner and immediate notification of the designated paediatrician or equivalent, if the death was unexpected or there is uncertainty about the cause of death.

9.3.16

Children who die in hospital will be reviewed by the CDOP for the area in which they were normally resident.

9.3.17

In the case of a looked after child, the CDOP for the area of the local authority looking after the child should exercise lead responsibility for conducting the child death review.

9.3.18

Where a young person dies at work, the Health and Safety Executive should be informed. Youth Offending Teams' reviews of safeguarding and public protection incidents (including the deaths of children under their supervision) should also feed into the CDOP child death processes.

9.3.19

If there is a criminal investigation, the team of professionals must consult the lead police investigator and the Crown Prosecution Service to ensure that their enquiries do not prejudice any criminal proceedings. If the child dies in custody, there will be an investigation by the Prisons and Probation Ombudsman (or by the Independent Police Complaints Commission in the case of police custody). Organisations who worked with the child will be required to cooperate with that investigation.

9.3.20

Any child who dies in a secure children's home, the Prisons and Probation Ombudsman will carry out an investigation. In order to assist the Ombudsman to carry out these investigations, secure children's homes are required to notify the Ombudsman of the death and to comply with requirements at regulation 40(2) of the Children's Homes (England) Regulations 2015 to facilitate that investigation.

9.3.21

The CDOP must review the circumstances of children who are normally resident in the area but who die abroad.


Consent and confidentiality

9.3.19

Information in CDOP meetings will not be anonymised.

9.3.20

It is best practice to seek consent before processing information about any individual, but it will be legitimate to share information with the designated paediatrician or equivalent, for unexpected deaths in childhood / the CDOP DP without seeking parental consent. It should only be shared with those who need to know, as governed by the Caldicott Principles, the Data Protection Act and Working Together to Safeguard Children.

9.3.21

CDOPs should have arrangements in place for parents and carers to be advised that the child's death will be subject to a review in order to learn any lessons that may help to prevent future deaths of children.

9.3.22

All Local Safeguarding Children Board member agencies must be aware of the need to share information on all child deaths to enable the Local Safeguarding Children Board to carry out its statutory duty.

9.3.23

Members of the CDOP must sign a confidentiality agreement, including sharing and securely storing information (there is a model confidentiality statement on the Local Child Death Contacts (London SCB) website) when they join the CDOP. This agreement should be reviewed at each meeting.

9.3.24

In no case should any CDOP member disclose any information pertaining to any individual case which has been dealt with by the CDOP outside the meeting, other than pursuant to the mandated agency responsibilities of that individual or for the purposes of joint investigations. Public statements about the general purpose of the child death review process may be made in line with the Local Safeguarding Children Board process for managing media interest (see Rapid response service for unexpected child death), as long as they are not identified with any specific case.


Learning from child deaths

9.3.25

The CDOP will monitor and advise the Local Safeguarding Children Board on the resources and training required locally to ensure an effective inter-agency response to child deaths.

9.3.26

The CDOP will identify any strategic issues (such as public health, community safety, health and safety etc) and consider how best to address these and their implications for both the provision of services and for training.

9.3.27

The CDOP will contribute to regional and national initiatives to identify lessons on the prevention of unexpected child deaths e.g. the London learning from information about child deaths initiative (see Local Child Death Contacts (London SCB) website).


Reporting mechanisms

9.3.28

Each CDOP must submit an annual report to its respective Local Safeguarding Children Board.

9.3.29

The Local Safeguarding Children Board is responsible for:

  • Disseminating the lessons to be learnt to all relevant organisations;
  • Ensuring that relevant findings inform the Children and Young People's Plan;
  • Acting on any recommendations to improve policy, professional practice and inter-agency working to safeguard and promote the welfare of children; and
  • Ensuring that data relating to child deaths is submitted to relevant regional and national initiatives to identify lessons on the prevention of unexpected child deaths.

9.4

Information sharing in relation to child deaths

 

9.4.1

Registrars of Births and Deaths are required by the Children and Young Persons Act 2008 to supply Local Safeguarding Children Board s with information which they have about the deaths of:

  • Persons aged under 18 in respect of whom they have registered or re-registered the death; or
  • Persons in respect of whom the entry of death is corrected and it is believed that person was or may have been under the age of 18 at the time of death.

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.

9.4.2

Registrars are required to send the information to the appropriate Local Safeguarding Children Board 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 Local Safeguarding Children Board 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.

9.4.3

In order to support these new responsibilities, it is a statutory requirement for each Local Safeguarding Children Board to make arrangements for the receipt of notifications from registrars and to publish these arrangements. In order to carry out this responsibility Local Safeguarding Children Boards are therefore required to notify the Department of Education of the name and email address for the Child Death Overview DP (hereafter referred to as the 'DP') in each Local Safeguarding Children Board to whom child death notifications should be sent. This information is published by the DfE - (A list of people designated by the Child Death Overview Panel to receive notifications of child death information is available at: the Department of Education website).


Duty and powers of coroners to share information

9.4.4

The Coroners and Justice Act 2009 and Coroners (Investigations) Regulations 2013 place a duty on coroners to inform the Local Safeguarding Children Board, for the area in which the child died, of the fact of an inquest or post mortem. It also gives coroners a duty to notify the LSCB for the area in which the child died or where the child's body was found within three working days of deciding to investigate a death or commission a post-mortem and to  share information with the Local Safeguarding Children Board s for the purposes of carrying out their functions, which include reviewing child deaths and undertaking serious case reviews. Where there is more than one Local Safeguarding Children Board in a coroner's area, arrangements should be made between the coroner and the Local Safeguarding Children Board s as to which Local Safeguarding Children Board should be informed of the coroner's decisions.

9.4.5

On receipt of an initial report of a death of a child, the Local Safeguarding Children Board or Local Safeguarding Children Boards 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 Local Safeguarding Children Board which it believes should be drawn to the attention of the relevant coroner, then the Local Safeguarding Children Board should consider supplying it to the coroner as a matter of urgency - (For further guidance see: www.justice.gov.uk/guidance/coroners-guidance.htm).


Duty and powers of medical examiners (MEs) to share information

9.4.6

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 Local Safeguarding Children Boards. It is anticipated that under the Coroners and Justice Act 2009, MEs will be required to share information with Local Safeguarding Children Boards about child deaths that are not investigated by a coroner.

Specific responsibilities of Clinical Commissioning Groups (Health and Social Care Act 2012)

9.4.7

CCGs should employ, or have arrangements in place to secure the expertise of, consultant paediatricians whose designated responsibilities are to provide advice on commissioning paediatric services from:

  • Paediatricians with expertise in undertaking enquiries into unexpected deaths in childhood;
  • Medical investigative services; and
  • The organisation of such services.


Definition of a preventable child death

9.4.8

A preventable child death is one in which modifiable factors may have contributed to the death. These are factors which, by means of nationally or locally achievable interventions, could be modified to reduce the risk of future child deaths - (See Working Together to Safeguarding Children 2015).

9.4.9

In reviewing the death of each child, the CDOP should consider modifiable factors, e.g. 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.


Use of child death information to prevent future deaths

9.4.10

Each CDOP should prepare an annual report of relevant information for the Local Safeguarding Children Board. This information should in turn inform the Local Safeguarding Children Board annual report. 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 Local Safeguarding Children Board annual report should serve as a powerful resource for driving public health measures to prevent child deaths and promote child health, safety and wellbeing.

9.4.11

The Local Safeguarding Children Board 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 Local Safeguarding Children Board 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.


9.5

Rapid response service for unexpected child deaths

 

Definition of an unexpected death of a child

9.5.1

An unexpected death is defined as the death of a child not anticipated as a significant possibility 24 hours before the death, or where there was a similarly unexpected collapse leading to or precipitating the events that led to the death.

9.5.2

The designated paediatrician or equivalent, responsible for child death (see 9.2.3 and 9.2.4, above) 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.


Rapid response remit

9.5.3

The service response to an unexpected child death should be safe, consistent and sensitive to those concerned, bereaved parents and siblings should receive a similar response across London.

9.5.4

Professionals should be aware that, in certain circumstances, separate investigative processes may be taking place alongside those described in this procedure (e.g. murder investigations, SUDI processes etc). Professionals and agencies should liaise across processes to avoid duplication.

9.5.5

The purpose of a rapid response service is to ensure that the appropriate agencies are engaged and work together to:

  • Ensure support for the bereaved family members, as the death of a child will always be a traumatic loss - the more so if the death was unexpected;
  • Identify and safeguard any other children in the household or affected by the death;
  • Respond quickly to the unexpected death of a child;
  • Make immediate enquiries into and evaluate the reasons for and circumstances of the death, in agreement with the coroner when required;
  • Enquire into and constructively challenge how each organisation discharged their responsibilities when a child has died unexpectedly (liaising with those who have ongoing responsibilities for other family members), and whether there are any lessons to be learnt;
  • Collate information in a standard format (see Local Child Death Contacts (London SCB) website) for details of national templates for Local Safeguarding Children Boards to use when collecting information about child deaths);
  • Co-operate appropriately post death, maintaining contact at regular intervals with family members and other professionals who have ongoing responsibilities to the family, to ensure that they are appropriately informed (unless such sharing of information would place other children at risk of harm or jeopardise police investigations);
  • Consider media issues and the need to alert and liaise with the appropriate agencies;
  • Provide bereavement support as needed, for any other children, family members or members of staff who may be affected by the child's death (see www.crusebereavementcare.org.uk).

See Key strands to rapid response for more information.

9.5.6

Rapid response begins at the point of death and ends when the final meeting has been convened and chaired by the designated paediatrician or equivalent. Any records of the meeting (i.e. Form B / meeting notes) should be forwarded to the CDOP at the time of the review.

9.5.7

The area in which the death of a child has been declared must take initial responsibility for convening and co-ordinating the rapid response process, until agreement for handover can be secured with the area where the child was normally resident. See 9.5.13 below for information around conflict resolution in cases where it is unclear where the child normally resided.

9.5.8

Where notified of a death abroad, the professionals responsible for child death in the local authority where the child is normally resident must consider implementing this procedure as far as is practically possible and fully record any decisions made.


Rapid response timeline

9.5.9

The Designated paediatrician or equivalent, is responsible for ensuring all actions relating to the rapid response process are completed. The rapid response timeline involves three phases:

  • Phase one (usually 0-5 days): the management of information sharing from the point at which the child's death becomes known to any agency until the initial results of the post-mortem have been completed;
  • Phase two (usually 5-7 days): the management of information sharing once the initial post mortem results are available; and
  • Phase three (usually 8-12 weeks): the management of information sharing through the case discussion meeting when the final post-mortem report is available.

9.5.10

It is important that all agencies are clear that the rapid response process is multi-dimensional, the information flow is variable, and that a number of different processes can occur at the same time.


Phase I: usually 0 - 5 days

Immediate response

9.5.11

Children who die unexpectedly in the community should be taken to an accident and emergency department (A&E) rather than a mortuary, and resuscitation should always be initiated unless clearly inappropriate. See the UK Resuscitation Guidelines (2010).

9.5.12

As with children who die in hospital, their parent/s should be allocated a member of hospital staff to support them throughout the process.

9.5.13

A child should not be taken to A&E in situations where:

  • The circumstances of the death require the child's body to remain at the scene for forensic examination (police will be involved in these cases and decisions will be made after consideration by the police Senior Investigating Officer); or
  • The death was expected in the context of the child's life limiting condition and they were receiving palliative care (the end of life care team must be involved in the decision on how to respond).

9.5.14

Where a child is not taken immediately to A&E, the professional confirming the death should inform the coroner, DP and the Designated paediatrician at the earliest opportunity. This death will be subject to local coronial guidelines if the doctor is unable to issue a Medical Certificate of the Cause of Death.

9.5.15

The families of children who are not taken to hospital should receive support throughout the process from a professional in the rapid response team whose role is to provide such support.


On arrival at hospital

9.5.16

As soon as practicable (i.e. as a response to an emergency) after arrival at a hospital, the child should be examined by the consultant paediatrician or delegated senior paediatric clinician on call. In some cases, this examination might be undertaken jointly with a consultant in emergency medicine, or for some children 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.

9.5.17

Where the cause of death or factors contributing to it are 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, 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: www.hta.gov.uk). The samples need to be agreed in advance with the coroner and should include the standard set (listed in Table 1 of Sudden Unexpected Death in Infancy (Royal College of Pathologists and Royal College of Paediatrics and Child Health, 2004)). Other samples may be required as guidance evolves. Consideration should always be given to undertaking a full skeletal survey, and if this is appropriate it should be done prior to autopsy.

9.5.18

In seeking to clarify the cause of death and the factors which contributed to it, the paediatrician should document:

  • A full account of any resuscitation and any interventions or investigations carried out;
  • An account by the carer, including narrative, of the events leading to the death; and
  • A body chart documenting the examination findings and any post-mortem changes.

9.5.19

When the child is pronounced dead, the medical paediatric or A&E consultant or delegated senior clinician should inform the parents, having first reviewed all the available information. S/he should explain future police and coronial 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. The medical consultant must seek consent from those with parental responsibility for the child if the tissue is to be retained beyond the period required by the coroner.

9.5.20

The parents should normally be given the opportunity to hold and spend time with their child in a quiet designated area. The allocated member of staff should maintain a discrete presence throughout.

9.5.21

The medical consultant who saw the child must inform the designated paediatrician or equivalent, immediately after the coroner is informed. 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.

9.5.22

The same processes will apply to a child who is admitted to a hospital ward and subsequently dies unexpectedly in hospital.

9.5.23

Professionals should be aware that, in certain circumstances, separate processes may be taking place alongside those described in this procedure (i.e. murder investigations, SUDI processes etc).


Immediate notification and information sharing

9.5.24

The Designated paediatrician or equivalent, is responsible for co-ordinating the multi-agency response, and must ensure that the following have been notified:

  • The coroner;
  • The police; and
  • Other agencies as appropriate (e.g. LA children's social care).

And, in a timely manner, will notify the CDOP.

9.5.25

The Designated paediatrician or equivalent, must ensure that information is shared and initiate a planning discussion between relevant agencies such as the police, health and LA children's social care (and others, including the coroner's office) in a timely manner to decide next steps. This may or may not involve a meeting.

9.5.26

Where the death occurred in a hospital, the plan should also address the actions required by the Trust's serious incidents protocol. Where the death occurred in a custodial setting, the plan should ensure appropriate liaison with the investigator from the Prisons and Probation Ombudsman.

9.5.27

Before leaving the hospital, or if the child died at home, before the professionals leave the home, the parents have the 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. Parents should be kept informed of the whereabouts of their child.

9.5.28

For each unexpected death of a child (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) 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 Youth Offending Team (YOT), the YOT should also be approached.


Police investigation

9.5.29

The police will begin an investigation into the 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.


Potential visit to the place where the child died

9.5.30

When a child dies unexpectedly in a non-hospital setting the senior investigating police officer and Designated paediatrician or equivalent, should make a decision about whether a visit to the place where the child died should be undertaken and who should attend. This should almost always take place for cases of sudden infant death  (Working Together to Safeguard Children)  (SUDI) - (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) (See paragraph 5.1 in the Kennedy Report)


Phase II: within 5 - 7days

9.5.31

A case discussion should take place within one week of the child's death, in order to:

  • Ensure the right support is available for the family;
  • Ensure all agencies are aware of their roles and responsibilities;
  • Review the preliminary post-mortem results (if available);
  • Identify any safeguarding concerns around surviving children, and refer accordingly to the police child protection team and LA children's social care;
  • Ensure agencies are collating information for Form B;
  • Ensure all relevant agencies are involved in the process;
  • Identify what further investigations or enquiries are required, agree which agency will undertake each task and agree timescales (which may not exceed those set out in this procedure) for doing so. If abuse or neglect appear to be possible causes of death, LA children's social care and the police should be informed and serious case review procedures considered.

9.5.32

Prior to this meeting, the Designated paediatrician or equivalent, should discuss the case with the pathologist (when a post-mortem has taken place and consent obtained from the coroner) and the police senior investigating officer, where appropriate.


Involvement of the coroner and pathologist

9.5.33

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 or equivalent, 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.

9.5.34

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.

9.5.35

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 Local Safeguarding Children Board child death core data set - (The nationally agreed dataset is available at the Department of Education website) - should be updated and, if necessary, previous information corrected.

9.5.36

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 serious case review processes in Serious Case Reviews Procedure should be followed. If there are concerns about surviving children living in the household, professionals should follow the procedures set out in Child protection enquiry.

9.5.37

In all cases, the designated paediatrician or equivalent, for unexpected child deaths or the Designated paediatrician or equivalent, 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.


Phase III: usually within 8 - 12 weeks

9.5.38

Further case discussion meeting should be convened and chaired by the Designated paediatrician or equivalent, following the final results of the post-mortem examination becoming available. This should involve those who knew the child and family and those involved in investigating the death - the GP, health visitors, school nurse, paediatrician/s, pathologist or pathologist report, police senior investigating officers, coroner or coroner's officer and, where relevant, social workers.

9.5.39

At this stage the collection of the Local Safeguarding Children Board child death core dataset - (The nationally agreed dataset is available at the Department of Education website) - should be completed. The purpose of the meeting 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 the future care for the family. Potential lessons to be learned may also be identified at this stage. The outcome of this meeting should inform the inquest, if there is one.

9.5.40

The meeting should explicitly address the possibility of abuse or neglect as causes or contributory factors in the death, and the outcomes of this should be recorded.

9.5.41

The meeting should agree how and by whom, the parents will be informed about the post-mortem results and the outcome of the meeting. The meeting should also agree how and by whom the parents will be provided with on-going support and given the opportunity to have their views taken into account by the CDOP review.

9.5.42

The Designated paediatrician or equivalent, must ensure that the results of the post-mortem examination are shared with parents, provided this is consistent with the requirements of the coroner and the police.

9.5.43

Where other investigations are ongoing, the meeting should conclude with a record of the current situation.

9.5.44

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 Local Safeguarding Children Board 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 Local Safeguarding Children Board area the case review meeting should be held. On occasion separate meetings may be appropriate in both Local Safeguarding Children Board areas, but good communication between the teams is essential.


9.6

Other related processes

 

9.6.1

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 assessment - see the Referral and Assessment Procedure or the relevant local assessment protocol. If concerns are raised at any stage about the possibility of surviving children in the household being abused or neglected, the inter-agency procedures should be followed - see the Referral and Assessment Procedure. Local authority children's social care has the 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.

9.6.2

If it is thought, at any time, that the criteria for a serious case review might apply, the Chair of the Local Safeguarding Children Board should be contacted and the Serious Case Review process should be followed. If a serious case review is initiated, the CDOP will not be able to conclude the child death reviewing process until after the serious case review report 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, prevent lessons from being learned and from being acted upon in a timely manner.

9.6.3

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.

9.6.4

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 NHS England 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.

9.6.5

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.

9.6.6

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.