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Child Death Overview Panel (CDOP) Practice Guidance Including Rapid Response Practice Guidance


Contents:

  1. Purpose
  2. Objectives
  3. Scope
  4. Membership
  5. Partner Agency Responsibilities
  6. Chair
  7. Governance
  8. Confidentiality and Information Sharing
  9. Accountability and Reporting Arrangements
  10. Child Protection Concerns
  11. Working with the Media
  12. Child Death Review Flowchart
  13. Rapid Response Practice Guidance
  14. Responding to the Death of a Child
  15. Response when a Child Dies following Admission to a Hospital Ward
  16. Immediate Response to the Unexpected Death of a Child in the Community
  17. Involvement of the Coroner and Pathologist
  18. Case Discussion following Preliminary Results of the Post Mortem Examination
  19. Discussing Post Mortem Results with the Parents / Carers
  20. Finalising the Involvement of the Rapid Response
  21. Good Practice Points for all Professionals Involved
  22. Factors that may Raise Concern
  23. Agency Guidelines
  24. Talking to Parents/Carers
  25. Training

    Further Information


1. Purpose

Through a comprehensive and multidisciplinary review of child deaths, the Hull Safeguarding Children Board Child Death Overview Panel (CDOP) aims to better understand how and why children in Hull die and use our findings to take action to prevent other deaths and improve the health and safety of our children.

In carrying out activities to pursue this purpose, the CDOP will meet the functions set out in Chapter 5 of 'Working Together to Safeguard Children 2015' in relation to the deaths of any children normally resident in Hull. Namely collecting and analysing information about each death with a view to identifying:

  1. Any case giving rise to the need for a Serious Case Review;
  2. Any matters of concern affecting the safety and welfare of children in Hull;
  3. Any wider public health or safety concerns arising from a particular death or from a pattern of deaths in Hull.


2. Objectives

  1. To ensure, in consultation with the local Coroner, that local procedures and protocols are developed, implemented and monitored, in line with the guidance in Chapter 5 of Working Together to Safeguard Children 2015 on enquiring into unexpected deaths;
  2. To ensure the accurate identification of and uniform, consistent reporting of the cause and manner of every child death;
  3. o determine whether the death was deemed preventable, that is, those in which modifiable factors may have contributed to the death. Modifiable factors defined as those, where, if actions could be taken through national or local interventions, the risk of future child deaths could be reduced;
  4. To collect and collate an agreed minimum data set of information on all child deaths in the Hull area and, where relevant, to seek additional information from professionals and family members;
  5. To evaluate data on the deaths of all children normally resident in the Hull area, thereby identifying 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;
  6. To evaluate specific cases in depth, where necessary to learn lessons or identify issues of concern;
  7. To identify significant risk factors and trends in individual child deaths and in the overall patterns of deaths in Hull, including relevant environmental, social, health and cultural aspects of each death, and any systemic or structural factors affecting children’s well-being to ensure a thorough consideration of how such deaths might be prevented in the future;
  8. To identify any public health issues and consider, with the Director(s) of Public Health and other provider services how best to address these and their implications for both the provision of services and for training;
  9. To identify and advocate where needed for changes in legislation, policy and practices to promote child health and safety and to prevent child deaths;
  10. To increase public awareness of issues that affect the health and safety of children;
  11. Where concerns of a criminal or child protection nature are identified, to ensure that the Police and Coroner are aware and to inform them of any specific new information that may influence their inquiries; to notify the Chair of the Hull Safeguarding Children Board of those concerns and advise the Chair on the need for further enquiries under Section 47 of the Children Act, or of the need for a Serious Case Review;
  12. To improve agency responses to child deaths through monitoring the appropriateness of the response of professionals to each unexpected death of a child, reviewing the reports produced by the Rapid Response Team and providing the professionals concerned with feedback on their work;
  13. To provide relevant information to those professionals involved with the child’s family so that they, in turn, can convey this information back in a sensitive and timely manner;
  14. To monitor the support and assessment services offered to families of children who have died;
  15. To monitor and advise Hull Safeguarding Children Board on the resources and training required locally to ensure an effective inter-agency response to child deaths;
  16. To co-operate with any regional and national initiatives – e.g. with the National Clinical Outcome Review Programme – to identify lessons on the prevention of child deaths in order to identify lessons on the prevention of child deaths.


3. Scope

The CDOP will gather and assess data on the deaths of all children and young people from birth up to the age of 18 years who are normally resident in Hull. (Excluding those babies who are stillborn and planned terminations of pregnancy carried out within the law (Abortion Act 1967).)

This will include neonatal deaths, expected and unexpected deaths in infants and in older children. Where a child normally resident in another area dies in Hull, that death shall be notified to the CDOP in the child’s area of residence. Similarly, when a child normally resident in Hull dies outside of the area, the Hull CDOP should be notified. In both cases an agreement should be made as to which CDOP (normally that of the child’s area of residence) will review the child’s death and how they will report to the other.

In cases where organisations in more than one LSCB area have known about or have had contact with the child, lead responsibility should sit with the LSCB for the area in which the child was normally resident at the time of death. Other LSCBs or local organisations which have had involvement in the case should cooperate in jointly planning and undertaking the child death review. In the case of a Looked After Child, the LSCB for the area of the local authority looking after the child should exercise lead responsibility for conducting the child death review, involving other LSCBs with an interest or whose lead agencies have had involvement as appropriate.


4. Membership

The CDOP will have a permanent core membership drawn from the key organisations represented on Hull Safeguarding Children Board. Other members will be co-opted as required to contribute to the discussion of certain types of death when they occur.

The Panel is chaired by a director in Public Health.

For up to date membership information, please contact the CDOP co-ordinator – Tel: (01482) 379090.


5. Partner Agency Responsibilities

Each partner agency of Hull Safeguarding Children Board will identify a senior person within their organisation who has responsibility for representing the agency on the CDOP. Each agency will ensure their representative is allocated sufficient time in their job plan to attend all Panel meetings, having prepared in advance of the meetings, and is able to report back to the agency any specific recommendations arising from the Panel.

Partner agencies will ensure that staff in their own agency who become aware of the death of a child report that child’s death to the Panel Co-ordinator. Partner agencies will ensure that relevant staff are made aware of the child death review functions of Hull Safeguarding Children Board and are able to access appropriate training (see Section 25, Training).

Specific Responsibilities of Relevant Bodies in Relation to Child Deaths
Relevant Bodies Responsibility
Registrars of Births and Deaths (Children & Young Persons Act 2008).

Requirement to supply the LSCB with information which they have about the death of persons under 18 they have registered or re-registered.

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.

Requirement to send the information to the appropriate LSCB (the one which covers the sub-district in which the register is kept) no later than seven days from the date of registration.
Coroners (Coroners Rules 1984 (as amended by the Coroners (Amendment) Rules 2008).

Duty to inquire and may require evidence.

Duty to inform the LSCB for the area in which the child died within three working days of the fact of an inquest or post mortem.

Powers to share information with LSCBs for the purposes of carrying out their functions, including reviewing child deaths and undertaking SCRs.
Registrar General (section 32 of the Children and Young Persons Act 2008). Power to share child death information with the Secretary of State, including about children who die abroad.
Medical Examiners (Coroners and Justice Act 2009). It is anticipated that from 2014 Medical Examiners will be required to share information with LSCBs about child deaths that are not investigated by a coroner.

Clinical Commissioning Groups (Health and Social Care Act 2012).

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, and from medical investigative services; and
  • The organisation of such services.


6. Chair

The Panel will be chaired by a representative of the Chair of Hull Safeguarding Children Board who is not involved directly in providing services to children and families in the area. The work of the Panel will be co-ordinated by the Hull Safeguarding Children Board Manager, supported by the Child Death Review Co-ordinator.


7. Governance

Matters will, where possible, be agreed by consensus; if an issue can not be agreed the matter will be decided by majority with the Chair. The Panel shall be quorate with one representative from each service, e.g.:

  • Hull Safeguarding Children Board;
  • Children’s Social Care;
  • Humberside Police;
  • Public Health; and
  • Designated Paediatrician.


8. Confidentiality and Information Sharing

The CDOP meetings will not be open to the public and their minutes will not be published in the public arena unless the members agree to do so. Information discussed at the CDOP meetings will be anonymised prior to the meeting. Information is being shared in the public interest for the purposes set out in Working Together to Safeguard Children 2015 and is bound by legislation on data protection.

CDOP members will all be required to sign a confidentiality agreement before participating in the CDOP. Any ad-hoc or co-opted members and observers will also be required to sign the confidentiality agreement. At each CDOP meeting all participants will be required to sign an attendance sheet, confirming that they have understood and signed the confidentiality agreement.

Any reports, minutes and recommendations arising from the CDOP will be fully anonymised and steps taken to ensure that no personal information can be identified.


9. Accountability and Reporting Arrangements

The CDOP is accountable to the Chair of Hull Safeguarding Children Board, and is responsible for developing a work plan, which should be approved by Hull Safeguarding Children Board. It will prepare an Annual Report for Hull Safeguarding Children Board, who will in turn, publish relevant, anonymised information.

Hull Safeguarding Children Board takes responsibility for disseminating the lessons to be learned to all relevant organisations, ensuring that relevant findings inform local strategic planning, and that any recommendations to improve policy, professional practice and inter-agency working to safeguard and promote the welfare of children in the area are implemented.

Hull Safeguarding Children Board will supply data regularly on every child death as required by the Department for Education to bodies commissioned by the Department to undertake and publish nationally comparable, anonymised analyses of these deaths.


10. Child Protection Concerns

Where there is an ongoing criminal investigation, the Crown Prosecution Service must be consulted as to what it is appropriate for the Panel to consider and what actions it might take in order not to prejudice any criminal proceedings.

If, during the enquiries, concerns are expressed in relation to the needs of surviving children in the family, discussions should take place with Children’s Social Care. It may be decided that it is appropriate to initiate a Children’s Social Care Assessment (see Assessment - Hull Children's Social Care Assessment Protocol).

If concerns are raised at any stage about the possibility of surviving children in the household being abused or neglected the Hull Safeguarding Children Board Core Procedures should be followed and a referral made to Children's Social Care (see Contacts and Referrals with Children’s Social Care Procedure). The Police and Coroner must be informed immediately that there is a suspicion of a crime or evidence comes to light that the death may be of a suspicious nature. The Chair of Hull Safeguarding Children Board should be informed of the case to ensure that appropriate procedures are followed and to consider the need for a Serious Case Review.


11. Working with the Media

All media interest in the work of the CDOP or individual cases currently, in the past or likely to be, considered by the CDOP will be dealt with by the Hull Safeguarding Children Board Manager, following consultation with the Hull Safeguarding Children Board Chair, the CDOP Chair and the Local Authority Director of Children and Family Services. All Freedom of Information requests made to agencies relating to the work of the CDOP must be notified to the relevant nominated officers.

Details of individual case discussions are to be kept confidential and in no circumstances will such details be passed to the press. All agencies are responsible for ensuring all relevant staff are aware of this.

The designated Hull Safeguarding Children Board press officers in consultation with the Hull Safeguarding Children Board/CDOP Chair will work proactively with the media to promote the work of the Board and the CDOP in safeguarding and promoting the welfare of children in Hull.

The annual report of the CDOP will be a public document and as such will have no identifiable information contained within. The report will be published on the Hull Safeguarding Children Board website.


12. Child Death Review Flowchart

Click here to view 'Child Death Review Flowchart'.


13. Rapid Response Practice Guidance

13.1 Definition

An unexpected death is defined as the death of an infant or child (less then 18 years old) which:

  • Was not anticipated as a significant possibility for example, 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.

The Designated Paediatrician responsible for unexpected deaths in childhood 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.

For the purpose of this practice guidance, all those under the age of 18 years will be referred to as a child.

13.2 Introduction to Rapid Response (RR)

The role of the Rapid Response in Hull is to enquire into and evaluate the unexpected death of each child in the Hull area. The Rapid Response is coordinated by the Designated Paediatrician, and includes other professionals who were involved with the child before or as a result of their death.

The joint responsibilities of the professionals involved with the child include:

  • Responding quickly to the child's death;
  • Maintaining a Rapid Response Protocol with all agencies, consistent with the Kennedy principles and current investigative practice from the National Police Chiefs' Council;
  • 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 types of enquiries/investigations that relate to the current responsibilities of their respective organisations. This includes liaising with those who have ongoing responsibilities for other family members;
  • Collecting information about the death in a standard, nationally agreed manner;
  • Providing support to the bereaved family, referring to specialist bereavement services where necessary and keeping them up to date with information about the child's death; and
  • Gaining consent early from the family for the examination of their medical notes.

In addition:

  • Where there are ongoing criminal proceedings, the Crown Prosecution Service in conjunction with Humberside Police should be consulted about appropriate action by the Rapid Response to avoid prejudicing any criminal prosecution;
  • Where the death is unnatural the Coroner has a statutory duty to investigate;
  • Where a child dies unexpectedly, all registered providers of healthcare services must notify the Care Quality Commission of the death of a service user – but NHS providers may discharge this duty by notifying the National Health Service Commissioning Board (Regulation 16 of the Care Quality Commission (Registration) Regulations 2009);
  • 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.

13.3 Principles

It must be remembered that, in most cases, the unexpected death of a child is the result of natural causes, and is a tragedy for the family.

The following principles should be adhered to at all times:

  • Respect, sensitivity, open mind, and discretion;
  • Achieving a balance between forensic and medical requirements and family support;
  • A multi-disciplinary approach;
  • Sharing of information;
  • Ensuring equality of service;
  • Recognising cultural needs, including language, faith and ethnicity;
  • Preserving evidence;
  • Good record keeping;
  • Working to the guidance as set out in Working Together to Safeguard Children 2015 and this document; and
  • Conducting enquiries expeditiously so that there are no unnecessary delays for the funeral.

If there are concerns that abuse or neglect may have been a factor, immediate consideration should be given regarding the needs of other children in the household. Guidance should be followed as provided in Hull Safeguarding Children Board guidelines and procedures.

13.4 Arrangements

Each partner agency of Hull Safeguarding Children Board should identify a senior member of staff, with relevant experience, to be responsible for advising on the implementation of Rapid Response, and the use of CDOP practice guidance, within their agency. This could be the CDOP member.

A Designated Consultant Paediatrician will be able to advise on:

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

The Designated Paediatrician for deaths in childhood will be a member of the 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.

13.5 Rapid Response Roles (RR)

Professionals involved before or after the unexpected death of a child are required to form a RR that should enquire into the death of the child. For this purpose certain roles will be required to work an on-call rota to enable such a response. The Hull Paediatrician covering 0-15 year olds coordinates the work of the RR. Other professionals who work as part of the team will carry out their normal functions. Apart from the Designated Paediatrician for deaths in childhood, other members of the Rapid Response may vary according to the circumstances of the child’s death.

When a child dies away from their normal place of residence, a joint decision will need to be made by the Rapid Response professionals in the LSCB (Local Safeguarding Children Board) area in which the death occurred and the Rapid Response in the child’s normal area of residence as to which team will lead the investigation and in which LSCB area the case review meeting should be held. On occasion separate meetings may be appropriate in both LSCB areas, but good communication between the areas is essential.

13.6 Care of Parents / Carers / Family Members

In circumstances when a child has died in, or been taken to a hospital, a member of the hospital staff should be allocated to remain with them and support them throughout the process.

The parents/carers should normally be allowed to hold and spend time with their child, if they wish. The allocated member of staff should maintain a discreet presence at this time.

If spoken English is not the preferred language of the parents / carers, interpreting services should be contacted if required. This should be communicated to the Designated Paediatrician who should inform other members of the RR. This also applies to any other additional requirements that parents / carers may have, e.g. physical disability.

When a child dies in the Hull area but their parents/carers live or are staying abroad, careful consideration needs to be given as to how best to contact the parents/carers and convey the information of the death of their child.

Unless sharing information may jeopardise a police investigation or criminal trial, parents / carers should always be kept up-to-date about any new findings. A member of the RR should be designated from the outset to liaise with the family, whenever possible, about such matters. This may be the Police Family Liaison Officer.


14. Responding to the Death of a Child

The response to an unexpected death will depend to a certain extent on the age of the child, but there are some key elements that underpin all subsequent work.

14.1 Immediate Response to the Unexpected Death of a Child taken to Hospital

Attempting Resuscitation and Conveying Children to Hospital who have Died

Children who die unexpectedly should be taken to the Emergency Department (A & E) of Hull Royal Infirmary if any attempt is to be made at resuscitation. Resuscitation should always be initiated unless clearly inappropriate. Children should not be removed from the scene if forensic examination is required.

Children will usually be conveyed to hospital by staff from Yorkshire Ambulance Service (YAS), and may also be accompanied by officers from Humberside Police. However, this will not always be the case, as sometimes they will be taken by families, friends or others.

If commenced, resuscitation should be continued according to the U.K Resuscitation Guidelines (2010), until an experienced Paediatrician has made the decision to stop. This will usually be the Consultant Paediatrician on-call.

Children dying at home or in a hospice or other setting who have been undergoing end of life care will not usually be considered to have died unexpectedly, and a Rapid Response to such deaths is rarely indicated.

When a child with a known life limiting or life threatening condition dies in a manner or at a time that was not anticipated, the Rapid Response 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. 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. E.g. 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. This death will be subject to local Coronial guidelines if the Doctor is unable to issue a Medical Certificate of the Cause of Death.

14.2 Obtaining the History of Events

As soon as practicable on arrival at the hospital, the child will be examined by the Consultant Paediatrician on-call. The Paediatrician or Emergency Department on-call Consultant should take a detailed history of events leading up to and following the discovery of the child’s collapse. This will help to establish the cause of death when appropriate, and help to identify if there are any suspicious circumstances. Any cause for suspicion should be reported to the on-call Detective Inspector and the Designated Paediatrician. The history and examination will be documented on the Emergency Department (A&E) proforma, and included in the hospital notes.

Some of the information will form part of the nationally agreed data set that has to be collected in relation to the death of each child.

14.3 Taking Samples

If the cause or circumstances of the death are uncertain, investigative samples should be taken immediately on arrival at the hospital and again after death is confirmed. These should be agreed in advance with the Coroner, in conjunction with the Paediatric Pathologist. They should include the standard set for Sudden Unexpected Deaths in Infancy, apart from routinely doing fibroblast culture, and for other types of death presentation as they present. Consideration should be given to undertaking a full skeletal survey, and when possible this should be made at the beginning of the autopsy as this may significantly alter the required investigations.

This may include taking particular tissue blocks and slides to ascertain cause of death. Consent from those with Parental Responsibility for the child will subsequently be required if tissue is to be retained beyond the period required by the Coroner (e.g. for possible future review or use in research).

14.4 Informing Parents / Carers of the Child’s Death

When the child is pronounced dead, the Consultant Paediatrician should inform the parents / carers, having first reviewed all the available information. They should explain about the future involvement of the Police, the Coroner and the RR.

If the Consultant Paediatrician, or other health care professional, becomes aware of any additional requirements of the parents/ carers e.g. communication or disability needs, this information should be relayed to the Designated Paediatrician.

CDOPs should ensure that at any time during the process, 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.

14.5 Informing the Coroner

The Doctor who has certified the death should inform the Coroner’s Office as soon as practicable unless the death was expected and is known to be completely natural, in which case a Medical Certificate for the Cause of Death (MCCD) will be issued. They should also ensure the Designated Doctor for Child Deaths is informed using the ‘Initial Notification’ Form A.

There is generally no on-call Coroner for out of hours referrals and in such cases the death should be reported at the outset of the next working day. However, in all sudden and unexpected deaths the Police will need to be informed of the death. This must happen without delay so that they can commence enquiries on behalf of the Coroner. Where the Police are involved they will complete a sudden death report form, which will be available to the Coroner. But the clinician is still required to report the death to advise the Coroner of the medical aspects.


15. Response when a Child Dies following Admission to a Hospital Ward

The above process should also be followed when a child dies unexpectedly following admission to a hospital ward.


16. Immediate Response to the Unexpected Death of a Child in the Community

16.1 Professionals First on the Scene

If the first professionals at the scene are not medical professionals, they must request assistance as the main priority. Resuscitation should always be commenced by any professional, unless it is clearly not appropriate.

If the child is not taken immediately to the Emergency Department, the professional who certifies the death should inform the Coroner and ensure the Designated Paediatrician for child deaths is also notified.

Ambulance personnel cannot certify the cause of death; they can only confirm the fact of death. The certification must be carried out by a Doctor.

16.2 Removing the Body from the Scene

In most circumstances, it will be appropriate to remove the child’s body from the scene and take it to the Emergency Department as soon as possible. However, if there are concerns that the death may be suspicious then the body should remain in place. Such a decision should be made by the YAS paramedics, in conjunction with the Senior Investigating Officer (SIO). This would require YAS personnel to confirm ‘life extinct’, and the SIO to state that the body cannot be removed until forensic examination is complete.

In most circumstances the child will already have been held or moved by a carer, therefore removing the body to the Emergency Department would not usually jeopardise an investigation.

16.3 Informing Relevant Professionals

Once the Designated Paediatrician for child deaths has been informed of the death, they must inform other relevant professionals. The Paediatrician may delegate this task to another to carry out on their behalf. Any relevant information held by Children’s Social Care should be shared promptly with Humberside Police and the Designated Paediatrician. The GP should also be informed of the child’s death and relevant information shared, as with any Health Visitor and School Nurse who has been involved with the child and / or family. Any special requirements that the family may have should be communicated to the above agencies at this time.

If the child dies away from home, then contact may be required with more than one local authority. If a child dies in Hull who is not a resident of the city, notification should be passed to the designated person in the local authority where the child was normally resident.

16.4 Sharing Information and Planning Meetings

When a child has died unexpectedly, the on-call Paediatrician should initiate an initial and immediate information sharing and planning discussion between the lead agencies, (e.g. Humberside Police and Children’s Social Care). This should take place prior to the home visit. This should include liaison with the Coroner’s Officer and any relevant others e.g. GP. The agreed plan should include a commitment to collaborate closely and communicate as often as necessary, often by telephone.

After the initial discussion has taken place, it is then the responsibility of the Designated Paediatrician to coordinate the response, as to what should happen next and plan who is responsible for particular actions. It should also include addressing any special requirements that the family may have, such as interpreting services.

Urgent contact should be made with any other agencies who know or are involved with the child, e.g. schools / nurseries, Child and Adolescent Mental Health Services (CAHMS), Connexions, Children's Centres, youth clubs etc. 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. This is to ensure that all relevant professionals who have been working with the child, as well as friends of the deceased at school e.g. do not hear of the death of the child via the media.

If the child died in hospital, the plan should also include actions required by the Trust’s serious incident protocol. If the child died in a custodial setting, the plan should ensure liaison with the Coroner and the investigator from the Prisons and Probation Ombudsman.

16.5 Role of the Police

Where appropriate the Police will conduct an investigation into the unexpected death of the child on behalf of the Coroner. In the case of suspicious deaths, this will be conducted in accordance with National Police Chiefs' Council guidelines.

16.6 Visits to the Scene of the Death

When a child dies outside of a hospital setting, the Senior Investigating Police Officer and the Designated Paediatrician should decide whether to visit the place where the child died. This should almost always happen in the case of sudden infant death. They should decide within 24 hours if the visit should take place. The visit should include talking to the parents / carers and examining the scene. They also need to decide if they should visit alone, or together. If they visit separately, they need to confer about their findings immediately on completion of the visits. Any specific requirements of the family should be considered and planned before undertaking the visit.

After this visit, the RR should review whether there is any additional information that raises concerns about the possibility of abuse or neglect contributing to the child’s death. If there are concerns about other children in the household, the processes laid out in Hull Safeguarding Children Board Child guidelines and procedures should be followed. If there are grounds for initiating a Serious Case Review, the Chair of Hull Safeguarding Children Board should be alerted.


17. Involvement of the Coroner and Pathologist

The Coroner will order a post mortem examination to be carried out, if they consider it necessary. This will be carried out by the most appropriate Pathologist available at that time, who may be either a Paediatric or Forensic Pathologist, or both. They will conduct the examination according to the guidance and protocols laid down by the Royal College of Pathologists.

The Designated Paediatrician should share information gathered from other professionals involved in responding to the child’s death and share it with the Pathologist conducting the post mortem, to inform the process.

Where the cause of death has not been determined at the post mortem examination or the death may have been unnatural, the Coroner will in due course hold an inquest.

On receipt of an initial report of a death of a child, Hull Safeguarding Children Board and / or any other LSCBs with an interest in this information should inform the Coroner of the address(es) to which future information should be supplied. The CDOP Administrator should inform the Coroner of their interest in the case, and submit a request to be informed of the date of inquest once listed, so that a representative can attend at the discretion of HM Coroner, and ask questions as a ‘properly interested person’.

If any information comes to the attention of Hull Safeguarding Children Board which it believes should be drawn to the attention of the relevant Coroner, it will be supplied to the Coroner as a matter of urgency.

The CDOP has a clear relationship and agreed channels of communication with the local Coronial Service.

All information collected by the RR should be included in a report provided by the Designated Paediatrician for the Coroner, which should be delivered within 28 days of the death of the child, unless there is vital information not yet available.


18. Case Discussion following Preliminary Results of the Post Mortem Examination

The preliminary results of the post mortem belong to the Coroner. In most cases it is possible for these to be discussed by the Paediatrician and Pathologist, along with the Senior Investigating Officer as soon as possible, and the Coroner should be informed of the initial findings. It is at this stage that the core data set should be updated, and if necessary any corrections to previous entries made to be audited.

In all cases, the Designated Paediatrician for deaths in childhood should convene a further RR discussion (usually by telephone) very shortly after the initial post mortem results are available. This discussion should usually take place within five to seven days after the child has died. They should review any further information that has come to light, that may raise additional concerns about safeguarding issues.

Further Discussion following the Final Results of the Post Mortem Examination

A case discussion meeting should take place as soon as the final post mortem results are available. The timing of this meeting will vary according to the circumstances of the death, and will take place anywhere from immediately after the post mortem to 3-4 months after the death. Which agencies are invited to attend will depend on the age of the child. It should include all those who knew the child and the family, as well as the Police who are likely to attend on behalf of the Coroner’s Office.

The meeting will be convened and chaired by the Designated Paediatrician for deaths in childhood. The main purpose of the case discussion meeting is to share information, to identity the cause of death and / or any factors that may have contributed to the death and then to plan future care and support for the family. This will include referral to bereavement services, if appropriate.

Potential lessons to be learnt may also be identified from the case discussion meeting. It will also inform the inquest via those attending on behalf of, or reporting back to, the Coroner. There should be an explicit discussion as to whether abuse or neglect was a cause or contributing factor in the child’s death. If there is no evidence of maltreatment, this should be specifically documented in the minutes of the meeting.

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/carers, and who will offer them on-going support.


19. Discussing Post Mortem Results with the Parents / Carers

The post mortem findings should be discussed with the parents / carers at the earliest opportunity, unless abuse or neglect is suspected and / or the Police are undertaking a criminal investigation. In such cases the Pathologist should discuss with the RR professionals what and when information can be shared with the parents / carers. The Designated Paediatrician responsible for the child’s care will initiate and lead the meeting.


20. Finalising the Involvement of the Rapid Response

An agreed record of the case discussion meeting and all reports should be sent to the Coroner, to consider as part of the inquest.

The record of the case discussion and the core data set should be made available to the Chair of the Hull Child Death Overview Panel or the Chair of any other CDOP if the child was not a Hull resident. This information should be analysed, and decisions made about what actions should be taken to prevent similar future deaths in the future.


21. Good Practice Points for all Professionals Involved

The first professional on the scene, whether ambulance personnel, Police or GP, should note the position of the child, the clothing worn and the circumstances of how the child was found. Those remaining at the scene should be asked not to disturb or move items around where the child was found until the Police, and also possibly the Paediatrician, have viewed it.

Any comments made by parents/carers, any background history, any possible substance misuse or other factors, and the living conditions should be noted and reported to the receiving Doctor at Hull Royal Infirmary. Any special requirements the parents / carers may have, such as communication needs or related to physical disability, should also be communicated to the receiving Doctor.

The following points are important to note:

  • Remember that you are dealing with people who are in the first stage of grief. They may be shocked, numb, withdrawn, or hysterical;
  • Always consider the need for an interpreter if spoken English is not the preferred language of the family;
  • Ask the child’s name and use it at all times;
  • Always handle the child as though s/he were alive;
  • It is entirely natural for a parent/carer to want to hold or touch the dead child. Providing this is done with a supportive professional (such as a Police Officer, Nurse or Social Worker) present, it should be allowed in most cases, as it is highly unlikely that forensic evidence will be lost. If, however, the death is by this time considered suspicious, the Senior Investigating Officer should, where possible, be consulted before a parent/carer is allowed to hold the child;
  • Record carefully what parents/carers say about the circumstances leading up to the death. This includes both early explanations and also later comments, which may produce conflicting accounts;
  • Record history and background information in as much detail as possible and without delay; professionals from all agencies may be required to provide statements of evidence;
  • Allow parents/carers time to ask questions;
  • Explain to parents/carers what will happen next, where their child will be taken and when they will be able to see him/her again;
  • Explain to parents/carers that all cases of sudden unexpected death must be referred to the Coroner and must be the subject of a multi-agency investigation;
  • If a post mortem examination is required, explain sensitively to parents/carers about why it is necessary and what is involved;
  • Take into account any religious and cultural beliefs that may have an impact on procedures and handle discussion of these with sensitivity, but with due regard to the importance of preserving evidence;
  • Avoid technical terms and jargon and when giving information, check it has been understood by parents/carers;
  • Your time with the family may be brief, but your presence at this tragic time may have great significance for them in time to come. It is vital to be sympathetic and supportive whilst maintaining a professional approach and to be mindful of the needs of siblings and other family members.


22. Factors that may Raise Concern

Any information identified by professionals in the course of their involvement that could give rise to concern or provide important information to the investigation must be shared immediately with the other professionals involved. Such factors (not in order of priority) include:

  • Previous child deaths in the same family;
  • Previous child protection concerns in the same family;
  • Previous unexplained illnesses or injuries;
  • Inappropriate delays in seeking help;
  • Inconsistent explanations;
  • Evidence of drug/alcohol abuse;
  • Evidence of parental mental health problems;
  • Unexplained injuries or bleeding;
  • Neglect issues.


23. Agency Guidelines

23.1 General Practitioner

GPs are often the first point of call for families when family members are unwell and as a result, it is entirely possible that GPs will be the first professional at the scene of an unexpected child death.

In cases where a GP is the first professional at the scene of an unexpected child death, they should, where appropriate, attempt resuscitation and arrangements should be made to transport the child to the Emergency Department. However, if it is apparent that resuscitation would be inappropriate and there is evidence that moving the body might disturb a potential crime scene, the child should be left in situ and the Police should be informed. The Police will make a decision as to whether a criminal investigation will be necessary.

A brief immediate history of the deceased should be taken at the scene to ensure that the Rapid Response will have as much information available to them to investigate the death. This should include circumstances of the death and information about the position and condition of the body on discovery.

Depending on the circumstances of the death, GPs will be contacted by Rapid Response professionals for information about the child and the family. The information provided will have a direct influence on both the decision made about the safety of any siblings and could inform any further investigations resulting from their preliminary findings. It is important that all information provided to the RR (and any other investigating team) is clear and accurate and can be supported by witness statements or evidence.

Rapid Response professionals are also responsible for ensuring that the family has access to support following the death and throughout the review process. This is often provided by a Family Liaison Officer or local equivalent depending on the circumstances of the death. However, GPs may be expected to provide further assistance such as medical support or referrals to national and local agencies and support services such as bereavement counselling.

GPs tend to have a greater knowledge of younger children than older children and there will be times when it seems that a GP would not be able to provide any insight into the death at all. GPs can also be invited to be part of the review process as they will be able to provide information about the family. In all circumstances, GPs should be mindful of patient consent and confidentiality.

The GMC document 0-18 years: guidance for all Doctors encourages Doctors to, (when possible) seek consent from children to share information with relevant parties; however, it is unlikely that consent will have been sought in all cases. The guidance states that the reasons for disclosure (without consent) are in circumstances when “(a) a child or young person is at risk of neglect or sexual, physical or emotional abuse; (b) the information would help in the prevention, detection or prosecution of serious crime, usually crime against the person; (c) a child or young person is involved in behaviour that might put them or others at risk of serious harm, such as serious addiction, self-harm or joy-riding.”

GPs are responsible for assessing the information that they hold about the child and other members of the family and considering the consequences of releasing this information to the review process. Issues relating to Fraser Competence should be considered and the effect that the disclosure of this information may have on the family must be considered and should only be released if absolutely necessary to the investigation. It is not advisable to release entire case notes to the review panel for the reasons stated above, and too much information may overwhelm the CDOP and make findings unclear.

23.2 Yorkshire Ambulance Service NHS Trust (YAS)

Resuscitation should always be commenced by YAS staff arriving at the scene, unless the child has clearly been dead for some time.

Where it is appropriate to attempt resuscitation and this is ongoing the child should be taken to the nearest appropriate Emergency Department with facilities to deal with a paediatric cardiac arrest.

Sometimes YAS personnel may not be able to establish the age of a child, in which case they are taken to the individual hospital based on an assumption of age.

Ambulance staff should follow current guidance as per Clinical Guidelines in Joint Royal Colleges Ambulance Liaison Committee (2006) and UK Resuscitation Council (2010) as follows:

  • Do not automatically assume that death has occurred;
  • Clear the airway and if any doubt about death apply full Cardio-Pulmonary Resuscitation (CPR);
  • Inform the Emergency Department at appropriate hospital of expected time of arrival and patient’s condition;
  • Take note of how the child was found;
  • Pass all relevant information to the medical team in the Emergency Department.

The Yorkshire Ambulance Service follows national guidance for the ‘Recognition of Life Extinct’ and the ‘Cessation of Resuscitation’. If YAS staff confirm life extinct, then liaison with the Police should occur as soon as possible. Police attendance at the scene should be requested via the YAS Access and Response Communications Centre as soon as possible. The attending Police officer in charge will decide if appropriate for YAS to convey the patient to hospital or leave the patient in situ.


23.3 Humberside Police

It is important for Police Officers to remember that most unexplained child deaths are the result of natural causes. Therefore, there needs to be a careful balance between consideration for the bereaved family and the potential of a crime having been committed. Officers should not routinely prevent parents/carers from holding their child as research shows that this would not destroy evidence. Only where there is evidence of severe external trauma should this be prevented.

If the Police are the first professionals to attend the scene, they should first request urgent medical assistance and then commence first aid until medical help arrives. If the child is being resuscitated, the carer should accompany the child to Hull Royal Infirmary, depending on the age of the child.

An Officer of at least Detective Inspector or Sergeant for Road Traffic Policing rank must attend the scene and the Coroner’s Office must be promptly informed.

In the first instance the parents/carers will be spoken to at the scene by the Police, who will explain the process and take a full history.

It is recommended the Police transport the parents/carers to hospital where they are not accompanying the child in the ambulance, where the Consultant Paediatrician on-call will have a private meeting with them.

As well as checking the list of children subject to a Child Protection Plan, in relation to all children in the household, the Police should ensure Police records are checked for all family members including Police National Computer (PNC), Crime Management System (CMS), and COMRAD (The Force incident Management System).

The attending SIO is responsible for deciding whether the death could possibly be of a suspicious nature, taking into account the circumstances at the scene, the family interviews and the checklist of factors of concern above. Police Officers must be mindful of factors which may be present in a natural child death, including:

  • Small quantities of gastric contents around the mouth;
  • In SUDIs froth emerging from the mouth and nose, possibly bloodstained, but not in older children;
  • Purple discolouration of the parts of the face and body that were lying downwards (caused by blood drainage under the skin after death);
  • Bedclothes covering the child’s head;
  • Wet clothing or bedding.

If it is considered the death may be suspicious, and it is deemed necessary to remove items from the house and take photographs and videos, then the attendance of Scenes of Crime Officer is essential. This should be handled with sensitivity to the feelings of the parents, to whom it should be explained this might help to find out why their child has died. (Before returning the items at a later stage the parents/carers should be asked if they want them back.)

A single Lead Officer should have responsibility for the interviewing of parents/carers; repeated questioning should be avoided, and personal radios, mobile phones should be switched off during the interviews. Tactful use of language will avoid causing unnecessary distress to the parents/carers and phrases such as ‘death scene’ should be avoided.

See also Guide to Investigating Child Deaths.

23.4 Hospital Staff in the Emergency Department (A&E)

No child should be examined in the ambulance. All children must be brought into the Emergency Department to facilitate a thorough assessment of the child and care of the family.

The parents/carers may stay with the child, or remain in the quiet room according to their wishes. In either case, a member of staff must be dedicated to their care.

A thorough physical examination should be carried out and carefully documented by the most senior Doctor available. It should include the following:

  • General state including cleanliness, clothing and nutrition;
  • Post death changes, such as dependent lividity, position and rigidity;
  • Signs of injury;
  • Core temperature;
  • Swabs if appropriate, e.g. nose, throat, eyes; and
  • Certify the child dead.

At this point there may be a need for discussion with the on-call Pathologist about taking routine samples if the post-mortem is to be delayed (e.g. over a Weekend / Bank Holiday), who may discuss this with the Coroner. Hospital staff should discuss this with the on-call Pathologist (during working hours / Pathology department on-call staff out of hours) and locally agreed procedures for taking samples should be followed.

When clothes, nappies etc. are removed they should be stored in individual labelled hospital bags and stay with the child initially.

Following this:

  • A call must be made to the Hull Children’s Social Care, to see if the child is on the List of children who have a Child Protection Plan;
  • Leave the child with the Nurse to clean and redress. Inform the Hospital Mortuary Attendants that a child will need to be conveyed to the mortuary in due course;
  • Inform the Emergency Department Consultant on-call and the Consultant Paediatrician on-call.

23.5 Pathologist and Coroner

After the fact of death is confirmed the Coroner has lawful control of the body. This does not apply to any samples taken during resuscitation.

However, for the purposes of this practice guidance the Coroner agrees to the specific samples being taken as soon as practicable after death, to assist the Pathologist in establishing the cause and circumstances of death. Consent of the family is not required and should not be sought, but the samples cannot be used for any other purpose.

Prior to the post-mortem, parents/carers should be offered photographs of the child, along with hand and foot prints and a small lock of hair. No items should be returned to the parents/carers at this stage.

The Coroner will identify a Pathologist to carry out the post mortem. This may be a Specialist Paediatric Pathologist or Home Office Pathologist. Protocols exist for undertaking post mortems in children under 2 years old.

The Senior Investigating Police Officer (SIO) is responsible for ensuring that both the Coroner and the Pathologist are provided with a full history at the earliest possible stage. This includes a full medical history from the consultant Paediatrician, any relevant background information concerning the child and the family, and any concerns raised by any agency.

Where appropriate, the Coroner’s Officer must ensure that the Designated Paediatrician for deaths in childhood and the Police are informed where and when the post mortem will be conducted. The family are entitled to be informed and to send their own medical representative. A Police Family Liaison Officer may also be appointed to assist the family, keep them informed and help them with the arrangements.

The SIO or a representative and the Scene of Crime Officer will usually attend the post mortem, depending on the circumstances and whether their presence is required. The Designated Paediatrician for deaths in childhood should also be invited.

The interim findings should be forwarded to the Designated Paediatrician for deaths in childhood and the Senior Investigating Officer, via the Coroner, as soon as the post mortem is completed. The Coroner has consented to the direct release of this information, for the purposes of this protocol, except where the death may be suspicious.

The Designated Paediatrician for deaths in childhood, or other designated professional from the Rapid Response team, will discuss them with the family with the agreement of the Coroner (unless criminal proceedings are being contemplated).

The GP responsible for follow-up should, on request, also receive a copy of the post mortem report from the Coroner, unless this is considered inappropriate because criminal proceedings are being contemplated, or, rarely, because of childcare issues.

The funeral should not be delayed unless there are good reasons for doing so. The parents/carers should be consulted as to whether any samples or whole organs are retained or returned to the body for funeral. Parents/carers should also be told if there will be a delay in returning any organ or tissue samples to the body after the post mortem. Tissue samples or whole organs will be handled in accordance with the Human Tissue Act, (2005) and may only be retained with parental consent once the Coroner has concluded the investigation. At this time the Paediatrician should also give parents/carers the opportunity to donate tissues or organs for therapeutic or research purposes.

This approach will ensure the inquest is informed by the clinical history, examination of the circumstances of death, thorough post mortem examination and multi-agency review.

23.6 Health Visitors and Midwives

Community Health Providers are commissioned to offer services including responding appropriately to an unexpected child death. Following assessment, of the family further services such as bereavement support may be offered as itemised in the service level agreements. The detail of this is contained within local protocols/ care pathways available from the service provider.

23.7 Children’s Social Care

If the death is unexpected or there are concerns about a suspicious cause of death, the Consultant or Designated Paediatrician for deaths in childhood will consult with Children’s Social Care (Access & Assessment Team or Immediate Help Team).

Children’s Social Care (CSC) Duty Manager must check records on notification of an unexpected child death and share relevant information.

If the child was in the care of approved foster carers, care staff, school staff or registered childminders at the time of death, the same procedure applies with the additional need to inform the Service Manager responsible for Looked After Children / staff concerned and/or Ofsted respectively.

If the child and/or family are known to Children’s Social Care, the Duty Manager must ensure that the relevant Operational Manager(s) and Head of Safeguarding and Development are informed. The City Children Safeguarding Manager of the local authority will inform the Director of Children and Family Services.

The Consultant or Designated Paediatrician, Police Investigating Officer and Children’s Social Care will confer and decide whether an immediate information sharing and planning discussion between the lead agencies will take place and decide what should happen next and who will do what.

The Duty Manager and child’s Social Worker or Manager (if allocated) must liaise with the Designated Paediatrician for deaths in childhood and attend the multi-agency planning meeting.

Children’s Social Care may need to become directly involved where there are specific support needs for the family, e.g. care of siblings, or child protection concerns arising from the circumstances of the death.

Where there are child protection concerns, the Hull Safeguarding Children Board guidelines and procedures will be applied and a child protection Strategy Meeting will be arranged by the Social Worker. Appropriate action should be agreed between the Police, medical staff and Children’s Social Care.

If there are grounds for considering initiating a Serious Case Review, The Chair of the Hull Safeguarding Children Board should be informed (and others as appropriate in relation to national guidance) and the process set out in separate guidance on Serious Case Reviews should be followed.


24. Talking to Parents / Carers

The most senior Doctor available should speak to the parents/carers. If the child had a life limiting illness or long term condition, an end of life care plan may be in place and should be referred to. At the hospital the following should be covered:

  • Explain to the parents/carers gently that the child has died;
  • Establish who are the parents/carers of the child and who has parental responsibility;
  • Take as full a history as is appropriate at the time, bearing in mind there will be another interview within 24 hours. The history should include pregnancy, birth, neonatal period, feeding history (in particular when exactly the child was last fed and what did the child eat), immunisations, drug history, development, family / social history, detailed history of last few days (and in particular the last 24 hours), when the child was last seen alive, actions and circumstances of parents/carers when the child was found dead / died, social history, whether the child is christened and any religious needs;
  • Allow them to ask any questions;
  • Ask if they wish anyone to come to be with them; and
  • Explain to them that information will be shared with other health professionals.

Families are seen in person by the Designated Paediatrician at various stages between death and review at panel to obtain information, answer any questions they have and signpost for additional support if required.

Approximately 6 weeks after the death, CDOP send a condolence letter to parents/carers. It explains why child death reviews are carried out and invites them to meet with the Hull Safeguarding Children Board Manager and a CDOP member or other professional known to them, to talk about information they have, views they think would help professionals understand how their child died, or help with questions they may have.

The letter is accompanied by a national leaflet which gives more detail on Child Death Review processes and national helpline numbers.

24.1 The Parents should also be told that:

  • The Coroner has to be informed of unexpected and unexplained deaths;
  • The Coroner has to confirm who has died, when and where they died, and establish the cause of death. The Coroner may arrange for a post mortem examination to take place, and if the cause of death remains uncertain or if the cause of death is not thought to be a “natural cause” (such as a fatal road accident) an inquest will be held;
  • Explain the role of the Rapid Response;
  • The Police may wish to have the child identified or visit the home with a Paediatrician, and/or Social Worker (RR). This main aims of the home visit are to establish where the child died and obtain further detailed information which may be helpful in establishing why the child died;
  • There are bereavement support services available, written information should be given regarding these services and how to contact them;
  • The staff will inform others if e.g. partner, grandparents, religious leader;
  • The Hull Safeguarding Children Board will be informed for the review they have to do for all child deaths.

The health professional supporting the family in the hospital should also:

  • Encourage them to see and hold the child, (but never leave them unsupervised);
  • After a short while encourage them to leave the hospital, (this can be difficult), and arrange transport for them;
  • Ask the parents/carers where they are going and document the address, contact telephone number, who will be with them, (they should not be alone), how they will get there safely, (they may need hospital transport);
  • Ensure that leaflets are given to reinforce what you have said, including leaflets that explain the roles of hospital / Coroner / RR / bereavement support / voluntary agencies etc. Document in the notes which leaflets were given to the parents/carers;
  • Provide the name of a designated professional in the RR and their telephone number, who will guide and support the parents/carers through the process.

When speaking to the parents/carers the senior doctor should bear in mind that:

  • The Coroner, the Police and Children’s Social Care Team has to be informed of unexpected and unexplained deaths, and the Coroner will be informed of any death certified within 24 hours of arrival at the hospital;
  • The Coroner will direct a post mortem examination and has control of the body. Mementoes and samples outside the terms of this protocol should not be taken without prior consultation. This does not apply to any samples taken during resuscitation. The consent of the family is not required and should not be sought but they can be reassured any samples cannot be used for any purpose other than the post mortem;
  • The Coroner will order a post mortem where necessary without the need for parental consent. However, it is now a requirement to determine the parents / carers wishes regarding the remaining tissue following the post mortem. Any organ or tissues taken at post mortem, which are not retained for microscopy, will be managed according to the parents'/carers' wishes. They can either:
    • Be returned to the Funeral Director after tests are complete and may be buried or cremated;
    • The funeral can be delayed, so the organs can be returned to the child, prior to the funeral;
    • Be donated for medical education, research or held as part of the medical record; or
    • The hospital can dispose of the tissues in a lawful way, usually by cremation.
  • In a Coroner’s post mortem the major organs will be removed and examined. Samples of tissue and fluids will be taken for later detailed inspection. The organs are then returned to the body (although they cannot be returned to their original position). The samples of tissue taken for testing can be kept as part of the child's medical records, providing parents / carers give consent for this. Keeping blocks and slides as part of the child’s medical records is always useful in case they are needed to answer further questions about the cause of death, or to help answer questions regarding illnesses of other family members in the future. However, nothing is retained without the consent of the family after the Coroner’s investigation is concluded, except in criminal cases where other legislation may have effect.

Parents / carers need a sensitive explanation of post mortem, which will enable them to understand the procedures and give informed consent about the use of tissue for teaching and research. They should also be given written information regarding post mortems, and a copy of Coroners and Inquests: a guide.

Doctors who obtain consent are strongly advised to receive training in the taking of consent before talking with the parents/carers. This is now a requirement of the Human Tissue Authority (HTA).

Action to be taken after the parents/carers have left:

  • The child is taken to the mortuary. The parents/carers can visit while the child is in the hospital, by arrangement with the mortuary staff;
  • Inform the GP to support the family;
  • Inform the Coroner who will need full name, date of birth, time of arrival, place of death, and a full history, including family contact details;
  • Inform the Paediatric Liaison Nurse at the Anlaby Suite;
  • Inform the Designated Nurse and Designated Doctor for Safeguarding (if there are child protection concerns);
  • Remember to support other staff and get support for yourself;
  • Follow up the case by discussing it with the Designated Paediatrician for deaths in childhood to find out the outcome;
  • If you have not already done so log an enquiry to see if the child is on the List of Children with a Child Protection Plan (Access & Assessment in Hull 01482 448879) even if there are no Child Protection concerns;
  • Complete the Hull Safeguarding Children Board’s child death Notification Form (A) and send to the Child Death Review Coordinator (details on the form).


25. Training

Using government training materials, Hull Safeguarding Children Board has developed training for staff from member agencies to understand and put into practice the child death review processes. This involves being able to take immediate action, provide appropriate support and care to the family, look at how and why children die and see if there are any lessons to be learned to help to prevent future deaths.

The purpose of these courses has been to develop expertise locally, based on our experience and feedback from parents and carers on implementing the local review of children’s deaths.

A 1-day training course Responding to an Unexpected Child Death provides staff, who are likely to be more directly involved when a child dies, with the basic skills to carry out an investigation into involvement and services provided to the child and family by agencies/organisations that knew them. The course is facilitated and assisted by designated professionals who lead on the rapid response process on behalf of their agency.


Further Information

This guidance should be read in conjunction with An Overview of the Child Death Review Process.

Sudden Unexpected Death in Infancy and Childhood - Multi-agency Guidelines for Care and Investigation (Royal College of Pathologists, endorsed by The Royal College of Paediatrics and Child Health)

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