1.17 Child deaths
The death of a child is a tragedy and enquiries should keep an appropriate balance between forensic and medical requirements and supporting the family at a difficult time. Professionals supporting parents and family members should assure them that the objective of the child death review process is not to allocate blame, but to learn lessons that could help prevent further child deaths.
The responsibility for ensuring a review takes place rests with the LSCB for the area where the child is normally resident. (If it is unclear in which area the child normally resided, the relevant CDOP Chairs should negotiate and agree who will lead the review.)
Other LSCBs or local organisations who have had involvement in the case should co-operate in jointly planning and undertaking the child death review.
In the case of a looked after child, the LSCB for the area of the local authority looking after the child should take lead responsibility for conducting the child death review, involving other LSCBs with an interest or whose lead agencies have had contact with the child.
- Reporting the death of a child
- Child Death Overview Panels
- Unexpected child deaths
- Responsibilities of organisation and agencies when an unexpected child death has been reported
- Responding to an unexpected child death
Reporting the death of a child
Professionals responding to a child's death should inform:
- the coroner, within one working day for unexpected child deaths
- the Designated Person (see below), and
- the police and Designated Paediatrician (or equivalent) if the death is unexpected or the cause of death is uncertain: see procedure on unexpected child deaths later in this chapter.
Registrars of Births and Deaths are required to notify the appropriate LSCB within seven days if they have registered or re-registered the death of persons under 18 or they have issued 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. This should enable the Designated Person to check that he or she has been notified of all child deaths in the area.
Coroners also have a legal 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.
The role of the Designated Person
Where a professional is aware of a child death they should inform the Designated Person in the area were the child is normally resident. The Department of Education have provided national templates to support the reporting of child deaths: national child death review forms. If the child’s death is unexpected, or the cause of death is uncertain, professionals should refer to the procedure on unexpected child deaths described later in this chapter.
LSCBs should also use all sources available, such as professional contacts or the media, to find out about cases when a child who is normally resident in their area dies abroad.
Once a notification has been received the Designated Person will establish which agencies/professionals have been involved with the child and family prior to, or at the time of, death. The Designated Person will send an agency report form – Form B of the national child death review forms – to these professionals.
All forms should be completed and returned to the Designated Person within 3 weeks by secure transfer.
All information from agencies will be collated into a single Form B and distributed to members of the Child Death Overview Panel for consideration.
Child Death Overview Panels
Membership of Child Death Overview Panels (CDOPs)
Each CDOP will have a fixed core membership drawn from the organisations represented on the LSCB and should include a professional from public health as well as other health professionals. In addition to the core members, the Panel may choose to co-opt other relevant professionals to discuss certain types of death as appropriate.
The Chair of the Panel should be appointed by the LSCB Chair and should not be involved directly in providing services to children and families in the area.
In some parts of the wider West Midlands, LSCBs have chosen to have shared panels. This can be beneficial as research has found that Panels responsible for reviewing deaths from larger populations are better able to identify significant recurrent contributory factors.
Role of the Child Death Overview Panels (CDOPs)
Each CDOP should:
- review ALL child deaths, excluding those babies who are stillborn and planned terminations of pregnancy carried out within the law
- collect and collate information on each child death and seek relevant information from professionals and, where appropriate, family members
- discuss each child's case and provide relevant information to those professionals who are involved directly with the family so that they can convey this information in a sensitive manner to the family
- determine whether the death was deemed preventable, that is, those deaths in which ‘modifiable factors’ may have contributed to the death. (Modifiable factors are those which could be influenced by local or national intervention.) The CDOP should then decide what, if any, actions could be taken to prevent future deaths
- make recommendations to the LSCB, or other relevant bodies, promptly so that action can be taken to prevent future deaths
- identify patterns or trends in local data and report these to the LSCB
- where a suspicion arises that neglect or abuse may have been a factor in the child's death, refer a case back to the LSCB Chair for consideration as to whether a Serious Case Review should be undertaken
- agree local procedures for responding to unexpected deaths of children
- co-operate with regional and national initiatives to identify lessons on the prevention of child deaths.
The CDOP is NOT responsible for determining the cause of death. This responsibility rests with the coroner or the doctor who signs the medical certificate of the cause of death.
The aggregated findings from all child deaths should inform local strategic planning, including the local Joint Strategic Needs Assessment, on how to best safeguard and promote the welfare of children in the area. Each CDOP should prepare an annual report of relevant information for the LSCB. This information should in turn inform the LSCB annual report.
Frequency of CDOP meetings
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 LSCB area.
Unexpected child deaths
An unexpected child death is defined as the death of a child which was 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. Unexpected deaths can occur when a child has a terminal illness.
If there is any doubt whether the child’s death meets the definition of an unexpected death, the processes for unexpected child deaths should be followed until the available evidence enables a different decision to be made.
Reporting an unexpected child death
If a child’s death is unexpected, or the cause of death is uncertain, professionals responding to the child’s death should inform:
- the coroner
- the police, and
- the Designated Paediatrician responsible for unexpected deaths in childhood or equivalent (see below).
The role of the Designated Paediatrician (or equivalent nominated professional)
The Designated Paediatrician responsible for unexpected deaths is responsible for:
- ensuring that relevant professionals (i.e. coroner, police and local authority children’s social care) are informed of any unexpected deaths
- co-ordinating the team of professionals (involved before and/or after the death) when a child dies unexpectedly (accessing professionals from specialist agencies as necessary to support the core team)
- convening multi-agency discussions after the initial and final post-mortem examination results are available.
Each Clinical Commissioning Group (CCG) is responsible for appointing the Designated Paediatrician. The Designated Paediatrician for child death may provide advice to more than one CCG, and is likely to be a member of the local CDOP. This is a separate role to the designated doctor for child protection, but does not necessarily need to be filled by a different person.
Other formal notifications
Where a child dies unexpectedly, all registered providers of healthcare services must notify the Care Quality Commission of the death of a service user. (NHS providers may discharge this duty by notifying NHS England).
Where a young person dies at work, the Health and Safety Executive should be informed.
Where a child 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.
Responsibilities of organisation and agencies when an unexpected child death has been reported
The police will begin an investigation into the sudden or unexpected death on behalf of the coroner.
The Designated Paediatrician (or equivalent nominated professional) should initiate an immediate information sharing and planning discussion between the lead agencies (for example, health, police and local authority children's social care) to decide what should happen next and who will do it.
All professionals involved with the child should jointly work together as a rapid response team to:
- identify and safeguard any other children in the household who may be affected
- respond quickly to the child's death
- make immediate enquiries (in agreement with the coroner) into the child death including evaluating the reasons for, and circumstances surrounding, the death
- liaise with the coroner and the pathologist
- undertake the types of enquiries/investigations that relate to the current responsibilities of their respective organisations
- collect information about the death
- provide support to the bereaved family, involving them in meetings as appropriate, referring to specialist bereavement services where necessary, and keeping them up to date with information about the child’s death
- gain consent early from the family for the examination of their medical notes.
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 co-operate with that investigation.
Where there are concerns about siblings under 19, local authority children’s social care must always be invited to attend rapid response meetings.
Responding to an unexpected child death
IMPORTANT: if at any stage in the process described below information arises that suggests there are safeguarding concerns about surviving children in the household, then a referral should be made to the relevant local authority children’s social care in accordance with chapter 5 of these procedures.
- Immediate response
If the child dies suddenly or unexpectedly at home or in the community, the child should be taken to an Emergency Department rather than a mortuary.
In some cases when a child dies at home or in the community, the police may decide that it is not appropriate to move the child’s body immediately (for example, because forensic examinations are needed).
- On arrival at hospital
As soon as possible after arrival at a hospital, the child should be examined by a consultant paediatrician and a detailed history should be taken from the parents or carers. This should help understand the cause of death and identify anything suspicious about it.
In all cases when a child dies in hospital, or is taken to hospital after dying, the hospital should allocate a member of staff to remain with the parents and support them through the process. The parents should normally be given the opportunity to hold and spend time with their child in a quiet area. The allocated member of staff should maintain a discrete presence throughout.
- Immediate notifications and information sharing
The Designated Paediatrician (or equivalent) must ensure that information is shared and initiate a planning discussion between all relevant agencies (such as the coroner’s office, police, health, and local authority children's social care etc.) in a timely manner to decide the next steps to be taken. This may or may not involve a meeting.
For more information on the organisations that should be notified see the section on reporting an unexpected child death above.
- Police investigation
The police will begin an investigation into the unexpected death 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 and/or the child’s main residence at time of death
The lead police investigator and a senior health care professional should decide whether there should be a visit to the place where the child died and/or the child’s main residence at time of death, how soon (ideally within 24 hours), and who should attend. This should almost always take place for cases of sudden infant death.
After this visit the lead police investigator, senior health care professional, GP, health visitor or school nurse and local authority children’s social care representative (etc.) should consider whether there is any information to raise concerns that neglect or abuse contributed to the child’s death. Consideration should be given to any need for action in respect of other children in the family/household.
- Involvement of the coroner
The coroner must investigate violent or unnatural death, or death of no known cause, and all deaths where a person is in custody or other state detention at the time of death.
The coroner will order a post mortem examination to be carried out as soon as possible and the Designated Paediatrician will collate and share information about the circumstances of the child's death with the pathologist to inform this process.
Professionals and organisations who are involved in the child death review process must co-operate with the coroner and provide him/her with a joint report about the circumstances of the child’s death. Where possible, this should not be led by the clinician who was responsible for the care of the child when they died. This report should include a review of all medical, local authority social care and educational records on the child. The report should be delivered to the coroner within 28 days of the death unless crucial information is not yet available.
- Multi-agency discussion of post-mortem results
Shortly after the initial post-mortem examination results become available, the Designated Paediatrician for unexpected child deaths should, when appropriate, convene a follow up multi-agency case discussion, including all those who knew the family and were involved in investigating the child’s death. This multi-agency case discussion should review any further information available, including any that may raise concerns about safeguarding issues. If the initial post mortem findings, or findings from the child’s history, suggest abuse or neglect as a possible cause of death the procedure for initiating a Serious Case Review should be followed and immediate action to safeguard surviving siblings commenced.
A further multi-agency case discussion may need to be convened by the Designated Paediatrician, or a paediatrician acting as their deputy, when the final post-mortem examination result is available. This is in order to share information about the cause of death or factors that may have contributed to the death and to plan future care of the family.
The Designated Paediatrician should arrange for a record of the discussion to be sent to the coroner to inform the inquest of the cause of death, and to the relevant CDOP to inform the child death review.
At the case discussion it should be agreed how detailed information about the cause of the child’s death will be shared with the parents, and by whom, and who will offer the parents on-going support.
The purpose of a Child Death Overview Panel (CDOP) is to undertake an overview of all child deaths within the local area. The CDOP should ensure that all other processes (for example, coronial enquiries, legal proceedings, serious case reviews etc.) have concluded before reviewing a child death, although data collection should continue in the meantime.
The CDOP should have a permanent core membership drawn from the key organisations represented on the LSCB. 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; children’s social care; the police. Other members should be co-opted as and when appropriate.
The functions of the CDOP include:
- reviewing all child deaths, excluding those babies who are stillborn and planned terminations of pregnancy carried out within the law
- collecting and collating information on each child and seeking relevant information from professionals and, where appropriate, family members
- discussing each child’s case, and providing 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
- determining 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
- making recommendations to the LSCB or other relevant bodies promptly so that action can be taken to prevent future such deaths where possible
- identifying patterns or trends in local data and reporting these to the LSCB
- where a suspicion arises that neglect or abuse may have been a factor in the child’s death, referring a case back to the LSCB Chair for consideration of whether a Serious Case Review is required
- agreeing local procedures for responding to unexpected deaths of children; and
- cooperating with regional and national initiatives – for example, with the National Clinical Outcome Review Programme – to identify lessons on the prevention of child deaths.