8.2 Unexpected Child Deaths
The following procedures apply whenever there is an unexpected death, whether the child was in the care of a parent, foster carer, children’s home, boarding school, child minder, day care provider, hospital or any other provider or any other carer.
It should be read in conjunction with the Reviewing Deaths of All Children - Role of the Child Death Overview Panel Procedure.
For any additional information or queries contact CDOP co-ordinator;firstname.lastname@example.org
This chapter was significantly updated in May 2016 and should be re-read.
- 1. Introduction
- 2. Responding to the Unexpected Death of a Child
- 3. Care of Parents and Family Members
- 4. The Involvement of the Coroner and Pathologist
- 5. The Involvement of the Police
- 6. The Involvement of Surrey Children’s Services
- 7. Multi-agency Working
An unexpected death is defined as the death of an infant or child (less than 18 years old) which was not anticipated as a significant possibility 24 hours before the death or where there was a similarly unexpected collapse or incident leading to or precipitating the events which led to the death.
Each CCG should employ or have arrangements in place to secure the expertise of a Consultant Paediatrician, whose designated responsibilities are 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;
- The organisation of such services.
The Designated Paediatrician for unexpected deaths in childhood is a separate role to the Designated Doctor for child protection but will not necessarily be filled by a different person.
The Specialist Nurse, Child Death Reviews, in conjunction with the Designated Paediatrician for Child Deaths will be responsible for arranging a meeting of the joint agency team in Surrey, in the event of an unexpected death. Professionals involved before or after the unexpected death of a child should form a team to enquire into and evaluate the child’s death. Some roles may require an on call rota for responding to unexpected deaths in their area. The work of the team will be co-ordinated by the Specialist Nurse and the Child Death Review Coordinator in conjunction with the Designated Paediatrician responsible for child deaths.
The team should work to a protocol which has been agreed with the local coronial service and their responsibilities include:
- Responding quickly to the unexpected death of a child in accordance with the locally agreed procedures;
- Maintaining a joint agency protocol with all agencies, consistent with the Kennedy principles and current investigative practice from the Association of Chief Police Officers;
- Making immediate enquiries into and evaluating the reasons for and circumstances of the death, in agreement with the Coroner;
- Liaising with the Coroner and the Pathologist;
- Undertaking the enquiries / investigations that relate to the current responsibilities of their respective organisations when a child dies unexpectedly. This includes liaising with those who have on-going responsibilities for other family members;
- Collecting information about the death in a standard, nationally agreed manner;
- Providing support to the bereaved family, providing opportunities for the family to have their views and voice heard, referring to specialist bereavement services where necessary and keeping them up to date with information about the child's death;
- Gaining consent early from the family for the examination of their medical notes; and
- Following the death, maintaining contact at regular intervals with family members and other professionals who have on-going responsibilities for other family members to ensure they are informed and kept up to date with information about the child’s death.
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.
Where a child dies unexpectedly, all health trusts, including CCGs, should also follow their locally agreed procedures for reporting and handling serious patient safety incidents (see the National Patient Safety Agency and the Core Standards on Patient Safety in the Standards for Better Health).
When dealing with an unexpected and/or unexplained death of a child of any age, staff in all agencies should bear in mind that each 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.
In all cases, enquiries should seek to understand the reasons for the child’s death, address the possible needs of other children in the household, the needs of all family members and also consider any lessons to be learnt about how best to safeguard and promote children’s welfare in the future.
If it is thought at any time that the criteria for a Serious Case Review might apply, the chair of the SSCB should be contacted and the Learning and Improvement Framework Procedure should be followed.
A multi-professional approach is required to ensure collaboration among all involved, including: Ambulance staff, Emergency department staff, Coroners’ officers, Police, General Practitioners (GPs), Health Visitors, School Nurses, Midwives, Paediatricians, Mental Health professionals, Hospital Bereavement staff, Voluntary agencies, Pathologists, Forensic Medical Examiners, Surrey Children’s Services, Probation, YOTs, Schools and any others professionals/agencies who may find themselves with a contribution to make in individual cases, for example, Fire Fighters or Faith Leaders.
2. Responding to the Unexpected Death of a Child
Immediate Response to the Unexpected Death of a Child in the Community - First Professional on the Scene.
If the first professionals on the scene are not medical professionals, then they must obtain urgent medical assistance as the first priority.
The Ambulance service or GP / Doctor should not assume death. They must:
- Initiate immediate resuscitation unless clearly inappropriate.
Resuscitation once commenced should be continued according to the UK Council Resuscitation Guidelines 2015 until an experienced doctor (usually the Consultant Paediatrician on call) has made a decision that it is appropriate to stop;
- Notify the police if they are not already present;
- If the child dies suddenly or unexpectedly at home or in the community, the child should normally be taken to the 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;
- Prior to arrival at the Emergency department, provide relevant information and history to Emergency department staff;
- Where a child is not taken immediately to the Emergency Department, the professional confirming the fact of the death should inform the Designated Paediatrician with responsibility for unexpected deaths in childhood at the same time as the Coroner is informed.
Immediate Response to the Unexpected Death of a Child taken to a Hospital
Emergency department staff and Paediatricians on duty should be informed prior to the child’s arrival at hospital; if that is not possible, then they must be informed immediately the child arrives 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. The purpose of obtaining this information is to understand the cause of death and identify anything suspicious about it. This should begin the process of collecting a nationally agreed data set. The Form B may be used by the Consultant to collect the agreed data set.
On arrival at the Emergency Department, staff should:
- Establish the identity of those present and their relationship to the child;
- 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;
- Check that the police have been notified if the child is dead on arrival or subsequently dies;
- Whilst resuscitating, undertake a full general examination, reporting on injuries, rashes and observations about the child’s physical condition;
- Inform the police immediately if injuries are noted or suspicions are raised;
- Obtain a full medical and family history, including siblings, history of other child deaths and medical concerns;
- Carefully record the site and route of any intervention in resuscitation;
- Ensure that personal mementos, clothing or bedding are not removed prior to consultation with the Coroner and Police;
- Explain to parents that the Coroner has to be informed to decide if a post-mortem will be necessary to try to discover the cause of death;
- Speak directly to the Coroner’s office;
- Where the causes of death or factors contributing to it are unknown, investigative samples should be taken immediately on arrival and after the death is confirmed. These samples have been agreed in advance with the Surrey Coroner (see SSCB website for sample list) and include the Multi-agency protocol for care and investigation of sudden unexpected death in infancy (SUDI) (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, when appropriate, it should be made before the autopsy is commenced as this may significantly alter the required investigations.
When the child is pronounced dead, the Paediatrician or ED consultant takes specimens of blood and urine for metabolic investigations, toxicology and to exclude infection (after death is declared, consent is not necessary for blood and urine specimens to be taken). The nature of any tests must be accurately recorded for the Pathologist.
When the baby or child is pronounced dead, the consultant clinician should inform the parents, having first reviewed all the available information. They should explain future Police and Coroner involvement including the latter’s authority to order a post-mortem examination. This may involve the taking of particular tissue blocks and slides to ascertain the cause of death. The consent for the retention of tissue samples would be the responsibility of the coroner’s officer. Consent from those with parental responsibility for the child is required for tissue to be retained beyond the period required by the Coroner (e.g. for use in research or for possible future review).
The Consultant Paediatrician on duty or Lead Health Child Safeguarding Professional will request and review medical records of the child and siblings and arrange for the records to be secured. Records will be available to the Police via the appropriate local arrangements.
The Consultant Paediatrician on duty, in liaison with the Police, should consider which other professionals may need to know. A senior member of Emergency department staff will contact all appropriate professionals and a copy of those professionals informed will be sent to the Child Death Coordinator within 24 hours.
Individual cases will need to be referred to Surrey Children’s Services if the child is Looked After, in receipt of current services from Surrey Children’s Services or if there are concerns about a suspicious cause of death. They will be informed of all child deaths via Surrey Children's Services or Emergency Duty out of hours.
The Consultant Clinician on call must contact the Designated Paediatrician with responsibility for unexpected deaths in childhood immediately after the Coroner is informed or on the next working day if out of hours.
The same processes apply to a child who was admitted to a hospital ward and subsequently dies unexpectedly in hospital.
Whenever and Wherever an Unexpected Death of a Child has occurred
The professional confirming the fact of death should consult the Designated Paediatrician with responsibility for unexpected deaths in childhood who will ensure in conjunction with the Specialist Nurse and Child Death Review Coordinator that relevant professionals (i.e. the Coroner, Police, Surrey Children’s Services, Health, Education and other professionals/agencies as appropriate) have been informed of the death. Contact may be required with more than one local authority if the child died away from home. Any relevant information identified by Surrey Children’s Services should be promptly shared with the Police and the Paediatrician. The Designated Nurse and Doctor for child protection should also be informed. The Specialist Nurse, Child Death Reviews will contact the relevant GP, Health Visitor, School Nurse or other relevant Health Professionals as a matter of routine practice in order 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 so that relevant information can be shared.
The Police will begin an investigation into the sudden or unexpected death of a child on behalf of the Coroner. They will carry this out in accordance with relevant ACPO guidelines.
When a child dies unexpectedly, a Paediatrician (on call or designated) should initiate an immediate information sharing and planning discussion between the lead agencies (i.e. Health, Police, Surrey Children’s Services) to decide what should happen next and who will do what. This will also include the Coroner’s officer and Consultant Paediatrician on call and any others who are involved (e.g. the GP if called out by the family or, for older children, the professional certifying the fact of death if they have already been involved in the child’s care / death). The agreed plan should include a commitment to collaborate closely and communicate as often as necessary, often by telephone.
When a baby or older child dies unexpectedly in a non-hospital setting, the Police Senior Investigating Officer and Specialist Nurse, Child Death Reviews should make a decision about whether a joint home/scene visit to the place where the child died should be undertaken. This should almost always take place for infants who die unexpectedly.
As well as deciding if the joint visit should take place, it should also be decided how soon (within 24 hours) and who should attend. It is likely to be a Senior Investigating Police Officer and a Health Care Professional (Specialist Nurse, Child Death Reviews experienced in responding to unexpected child deaths) who will visit, talk with the parents and inspect the scene. They may make this visit together, or they may visit separately and then confer.
After this visit, the Senior Investigating Police Officer, Specialist Nurse, GP, Health Visitor or School Nurse and Surrey Children’s Services representative should review whether there is any additional information that could raise concerns about the possibility of abuse or neglect having contributed to the child’s death.
If there are concerns about surviving children in the household, the Managing Individual Cases Procedures in this manual should be followed. If there are grounds for considering initiating aSerious Case Review, the Serious Case Review Procedure should be followed.
The Designated Paediatrician/Specialist Nurse should ensure that the minutes of the Post Child Death Review meeting which include details of the history taken in the Emergency department, the home visit and a scrutiny of all available records is made available to the Coroner.
All professionals must ensure that they retain a written record of the initial referral to them and take note of:
- The position of the child, the clothing worn and the circumstances of how they were found;
- Explanations for any injury and any discrepancies;
- Comments made by the parents;
- Background history, any possible alcohol / drug misuse and the conditions of the living accommodation;
- Any known underlying medical condition the child may have.
All professionals should provide all the above information and, where applicable, any suspicions must be provided to the receiving Doctor and the Police immediately.
The comments of parents must be noted in detail.
Anyone who contributes to the written records must legibly sign, date and put their designation / role.
Responding to deaths of children with life limiting diseases
Chronic illness, disability and life limiting conditions account for a large proportion of child deaths. Whilst it is to be expected that children with life limiting or life threatening conditions (LL/LT conditions) will die prematurely young, it is not always easy to predict when, or in what manner they will die. Professionals responding to the death of a child with a LL/LT condition should ensure that their response to these families is appropriate and supportive, does not cause any unnecessary distress at a time when they are dealing with the tragic but anticipated, natural death of their child, and that their child's expected death can be dignified and peaceful. End of life care plans may be in place and therefore families, where appropriate, should be supported, to choose where their child's body is cared for after death for example a children's hospice. The lives of children with LL/LT conditions are as valued and important as those of any other children, and hence the unexpected, death of a child with LL/LT conditions should be managed as for any other unexpected death so as to determine the cause of death and any contributory factors. This is both out of respect for the child and family, and to fulfil any statutory requirements.
Children dying at home or in a hospice or other setting who have been undergoing end of life care will not usually be considered to have died unexpectedly, and a joint agency response to such deaths is rarely indicated.
When a child with a known life limiting and or life threatening condition dies in a manner or at a time that was not anticipated, the joint agency team should liaise closely and promptly with a member of the medical, palliative or end of life care team who knows the child and family, to jointly determine how best to respond to that child's death.
This should include consideration of whether the child's body should be transferred to a hospital or hospice, and whether any investigations or inquiries are required. Where an end of life plan has been agreed by the end of life care team and is in place, this should be followed unless there are pressing reasons not to do so. For example, the Coroner decides where the child's body may be taken and this decision may be different to what was set out in the family's prepared plan.
Children who die at home or in a hospice or other setting in which thy have been in receipt of planned end of life care will not normally be considered to have died unexpectedly, and therefore should not usually be moved to a Hospital Emergency Department. Parents whose children die at home in such circumstances may wish their child to remain at home, or to be taken to a hospice cool room. This death will be subject to local Coronial guidelines if the doctor is unable to issue a Medical Certificate of the Cause of Death.
3. Care of Parents and Family Members
Where a child has died in or been taken to a hospital, the parents should be allocated a member of hospital staff to support and keep them informed throughout the process. The parents should normally be given the opportunity to hold and spend time with their baby or child (including in the mortuary). During this time the allocated member of staff should maintain a discrete presence.
There should be arrangements for an identified professional to provide similar support to families where the child has not been taken to a hospital. This support is offered by the Specialist Nurse, Child Death Reviews.
Where a child is living in England but their parents live abroad, careful consideration should be given to how best to contact and support the bereaved family members.
Parents should be kept up to date with information about their child’s death and the involvement of each professional unless such sharing of information would jeopardise police investigations or other criminal processes.
4. The Involvement of the Coroner and Pathologist
If a doctor is not able to issue a medical certificate of the cause of death, the Lead Professional or Investigator must report the child's death to the Coroner in accordance with a protocol agreed with the local Coronial service. The Coroner must investigate violent or unnatural death, or death of no known cause, and all deaths where a person is in custody at the time of death. The Coroner will then have jurisdiction over the child's body at all times. Unless the death is natural, a public inquest will be held. See Ministry of Justice Guidance for Coroners and Local Safeguarding Children Boards on the Supply of Information Concerning the Death of Children.
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 will collate and share information about the circumstances of the child's death with the Pathologist in order to inform this process.
If the death is unnatural or the cause of death cannot be confirmed, the Coroner will hold an Inquest. Professionals and organisations who are involved in the child death review process must cooperate with the Coroner and provide him/her with a joint report about the circumstances of the child's death. This report should include a review of all medical, Surrey Children’s Services 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.
Although the results of the post mortem belong to the Coroner, it should be possible for the Designated Paediatrician, Specialist Nurse, Pathologist, and the Lead Police Investigator to discuss the findings as soon as possible, and the Coroner should be informed immediately of the initial results. If these results suggest evidence of abuse or neglect as a possible cause of death, the Designated Paediatrician should inform the Police and Surrey Children’s Services immediately. He or she should also inform the SSCB Chair so that they can consider whether the criteria are met for initiating an SCR.
When the final post mortem results become available, the Specialist Nurse in conjunction with the Designated Paediatrician for unexpected child deaths should convene a multi-agency case discussion, including all those who knew the family and were involved in investigating the child's death. The professionals should review any further available information, including any that may raise concerns about safeguarding issues, 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 and Specialist Nurse should arrange for a record of the discussion to be sent to the Coroner, to inform the inquest and 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, and by whom, with the parents, and who will offer the parents on-going support.
5. The Involvement of the Police
The police must be informed of all child deaths.
Police attendance should be kept to the minimum required and officers need to be sensitive to the distress caused by uniforms, marked police cars, personal radios and mobile phones.
A substantive Detective Sergeant, or above, must attend all scenes and a Detective Inspector must attend if there are suspicions of abuse or neglect.
The Safeguarding Investigation Unit (SIU) should be notified and may be involved. Such officers have skills and knowledge within the field of child protection and inter-agency working which will be helpful in the investigation.
The PPIU must be involved where there are any concerns for other children in the family / household.
Close liaison must be maintained throughout the investigation with Coroner’s office.
The senior Detective attending will be responsible for deciding on the attendance of a scene of crime officer (SOCO), and deciding the level of investigation.
The Paediatrician is responsible for obtaining the fullest history of events and the Police should avoid repeat questioning by different officers. Wherever possible the Police Senior Detective and the Paediatrician should confer and agree a joint assessment.
6. The Involvement of Surrey Children’s Services
The duty manager at Surrey Children's Services must check records on notification of an unexpected child death.
If the child and/or family are known to Surrey Children’s Services (open or closed case) other than merely through school attendance at a local or other school or registered day care provider and there is cause to be concerned about possible neglect or abuse, the manager must inform the Safeguarding Children Manager who should arrange to:
- Secure the file;
- Inform the appropriate Service Manager, Head of Surrey Children’s Services and the Director of Surrey Children’s Services.
Initial information-sharing and planning discussion held in ED between Lead Clinician, Police and Social Care (to include information from the Ambulance crew; Discussion to be documented in child’s records).
Any Section 47 Enquiry planned by the Strategy Meeting/Discussion must be conducted within the child protection procedures framework – see Section 3 of this manual, Safer Workforce and Managing Allegations Against Staff, Carers and Volunteers.
7. Multi-agency Working
Joint Agency Meeting/Discussion
The Specialist Nurse in conjunction with the Designated Paediatrician with responsibility for unexpected deaths in childhood must convene a joint agency meeting/discussion (usually via telephone/email communications) within 24 hours of the unexpected death of a child or 24 hours from the next working day if the death occurs at a weekend or holiday.
The purpose of this meeting/discussion will be to:
- Decide whether the Specialist Nurse, Child Death Reviews will visit the family, alone or with the police, within 24 hours in order to gather information about the child, family and circumstances of death, explain the investigation process and offer support;
- Consider who else should visit the family to offer support and gather any further information;
- Share information from case notes / documentation which may shed light on the circumstances leading up to the child’s death, including any unexplained or unusual deaths / health problems in the family, neglect or failure to thrive, unusual presentations of the child, parental substance misuse or mental health difficulties, domestic violence and any child protection concerns;
- Explain the Medical Professionals’ understanding of cause of death, if they have one;
- Consider if there are any child protection risks to siblings and/or any other children in the household and ensure these are referred to Surrey Children’s Services if this has not already been done;
- Ensure a co-ordinated bereavement care plan for the family;
- Organise a review multi-agency meeting, when all information, including the post mortem report, will be available.
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 proper liaison with the Investigator from the Prisons and Probation Ombudsman.
If there is a possibility that the criteria for a Serious Case Review might apply, the Chair of the SSCB should be contacted and the Serious Case Review Procedure should be followed.
Participants to the Post Child Death Review meeting
The following agencies may be included in the meeting/discussion:
- Health: The Designated Paediatrician with responsibility for unexpected death in childhood, Specialist Nurse, Child Death Reviews, the doctor who certified death, the Designated Doctor and Nurse for child protection, named Health Visitor, School Nurse, Midwife, Ambulance service, GP and the Consultant Paediatrician responsible for the child;
- Surrey Children’s Services: the responsible team / duty manager or their representative;
- Police: PPIU and responsible unit for investigating the child’s death;
- Additional contributors may include the school, nursery / pre-school;
- Legal advice should be sought as required.
Post Child Death Review meeting following receipt of the final post mortem report.
The preliminary results of the post-mortem examination belong to the commissioning Coroner. In most cases it will be possible for these to be discussed by the Designated Paediatrician, Specialist Nurse, Child death Reviews and Pathologist, together with the Senior Investigating Police Officer, as soon as possible and the Coroner should be immediately informed of the initial results.
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 Surrey Children’s Services should be informed immediately and the Serious Case Review Procedure followed
If there are concerns about surviving children living in the household the procedures set out in Part 4 of the Manual, Managing Individual Cases should be followed with respect to these children.
In all cases, the Specialist Nurse in conjunction with the Designated Paediatrician for unexpected child deaths should convene and chair a further multi-agency discussion meeting shortly after the final post-mortem results are available. This discussion should involve the Pathologist, Police, Surrey Children’s Services and Paediatrician plus any other relevant healthcare professionals, to review any further information that has come to light which may raise additional concerns about safeguarding issues. Professionals involved in the meeting will include those who knew the child and family and those investigating the death.
At this stage the core data set should be updated and, if necessary, previous information corrected in a manner that enables this change to be audited.
The main purpose of this case discussion is to share information to identify the cause of death and/or those factors that may have contributed to the death and then to plan future care for the family. Potential lessons to be learnt may also be identified by this process. Another purpose is to inform the Inquest.
There should be an explicit discussion of the possibility of abuse or neglect either causing or contributing to the death. If there is no evidence of this it should be documented in the minutes of the meeting.
The meeting must agree how the detailed information about the cause of the child’s death will be shared with the parents, and by whom, and who will offer them and other family members including surviving siblings’ on-going support.
The Specialist Nurse in conjunction with the Designated Paediatrician must ensure an agreed record of the Post Child Death Review meeting is be sent to the Coroner, to take into consideration in the conduct of the inquest.
Potential lessons to be learnt may be identified by this process. Another purpose is to inform the Inquest.
The results of the post mortem examination should be discussed with the parents at the earliest opportunity, except in those cases where abuse is suspected and/or the Police are conducting a criminal investigation. In these situations the Paediatrician should discuss with Surrey Children’s Services, the Police and Pathologist what information should be shared with the parents and when. This discussion with the parents will usually be part of the role of the Paediatrician responsible for the child’s care, and they will therefore have responsibility for initiating and leading the meeting. A member of the primary health care team should usually attend this meeting.
An agreed record of the Post Child Death Review meeting and all reports should be sent to the Coroner, to take into consideration in the conduct of the inquest.
At this stage the collection of the core data set should be completed and, if necessary, previous information corrected in a manner that enables this change to the information to be audited.
The data set and any other reports should be made available to the Surrey Child Death Overview Panel - see Reviewing Deaths of All Children - Role of the Child Death Overview Panel Procedure.
The record of the case discussions and the record of the core data set should also be made available to the local Child Death Overview Panel when the child dies away from their residential area.
The following principles must be maintained:
- Open mind, sensitivity, discretion and respect;
- Balance between forensic and medical requirements and the family’s support needs;
- A multi-disciplinary approach;
- Sharing of information;
- Appropriate response to the circumstances;
- Recognition of cultural need;
- Preservation of evidence;
- Good record keeping;
- Working to a protocol agreed with the local Coronial service;
- The need to conclude any enquiries or investigations expeditiously so the funeral is not delayed unnecessarily.