London Logo


Top of page

Size: View this website with small text View this website with medium text View this website with large text View this website with high visibility

12. Unexpected Death of a Child

This Chapter will be replaced by a supplementary procedure outlining the London response to all child deaths, available from April 2008 at: the London Safeguarding children board website

Contents


12.1 Unexpected Death of a Child
12.1.1 Definition
12.1.2 Arrangements
12.1.10 Principles
12.2 Responding to the Unexpected Death of a Child
12.2.1 Immediate Response to the Unexpected Death of a Child in the Community
12.2.4 Immediate Response to the Unexpected Death of a Child taken to Hospital
12.2.13 Whenever and Wherever an Unexpected Death of a Child has Occurred
12.3 Care of Parents/Family Members
12.4 The Involvement of the Coroner and Pathologist
12.5 The Involvement of the Police
12.6 The Involvement of LA Children's Social Care
12.7 Multi-agency Working
12.7.1 Multi-agency Planning
12.7.7 Participants to the Multi-agency Planning Meeting
12.7.10 Case Discussion Following Preliminary Results from Post Mortem
12.7.14 Case Discussion following Final Results from Post Mortem
12.8 Child Protection Enquiry


12.1


Unexpected Death of a Child
This section will be replaced by a supplementary procedure outlining the London response to all child deaths, available from April 2008 at the London Safeguarding children board website.


Definition
12.1.1 An unexpected death is defined as the death of a child (birth to 18 years, excluding babies stillborn) which was not anticipated as a significant possibility 24 hours before the death or where there was a similarly unexpected collapse leading to or precipitating the events which led to the death.


Arrangements
12.1.2  The Local Safeguarding Children Board (LSCB) regulations mean that the child death review functions will become compulsory on 1 April 2008. Procedures on child death reviews should not be regarded as statutory guidance in every local authority area until 1 April 2008 but when an LSCB takes on this function before that date, then it should follow the guidance in this section.
12.1.3 This section is based on the chapter seven of Working Together to Safeguard Children (DfES, 2006), and is subject to amendment as arrangements develop towards April 2008.
12.1.4  In each partner agency of the LSCB, a senior person with relevant experience should be identified as having responsibility for advising on the implementation of local procedures for responding to child deaths within their agency.
12.1.5

Each Primary Care Trust (PCT) should have access to a consultant paediatrician who has a designated role 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.
12.1.6  The designated paediatrician for unexpected deaths in childhood may provide advice to more than one PCT and is likely to be a member of the local child death overview panel.  This is a separate role to the designated doctor for child protection but will not necessarily be filled by a different person.  These responsibilities must be recognised in the job plan agreed between the consultant and their employer.
12.1.7

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 should normally be co-ordinated by the local 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;
  • Making immediate enquiries into and evaluating the reasons for, and circumstances of the death, in agreement with the coroner;
  • 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 ongoing responsibilities for other family members;
  • Collecting information in a standard, nationally agreed manner;
  • Following the death through and maintaining contact at regular intervals with family members and other professionals who have ongoing responsibilities for other family members to ensure they are informed and kept up to date with information about the child's death.
12.1.8  Where there is an ongoing criminal investigation, the Crown Prosecution Service must be consulted as to what is appropriate for the professionals to be doing and what actions to take in order not to prejudice any criminal proceeding.
12.1.9  Where a child dies unexpectedly, all health trusts, including PCTs, should also follow their locally agreed procedures for reporting and handling serious patient safety incidents (see the National Patient Safety Agency's website and the core standards on patient safety in the standards for better health)


Principles
12.1.10  When dealing with an unexplained death of a child of any age, staff in all agencies should bear in mind that in most cases the deaths are the result of natural causes and represent an unavoidable tragedy for the family.
12.1.11 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.
12.1.12 If it is thought at any time that the criteria for a serious case review might apply, the chair of the LSCB should be contacted and the serious case review procedures set out in section 19. Serious case reviews should be followed.
12.1.13

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.
12.1.14  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.  Children with a known medical condition and disabled children should be responded to in the same manner as other children.
12.1.15 A multi-professional approach is required to ensure collaboration among all involved, including: ambulance staff, accident and emergency department staff, coroners' officers, police, general practitioners (GP's), health visitors, school nurses, midwives, paediatricians, mental health professionals, hospital bereavement staff, voluntary agencies, coroners, pathologists, forensic medical examiners, LA children's social care, probation, schools and any others who may find themselves with a contribution to make in individual cases, for example, fire fighters or faith leaders.


12.2


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
12.2.1  If the first professionals on the scene are not medical professionals, then they must obtain urgent medical assistance as the first priority.
12.2.2 

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 Resuscitation Guidelines (2005) 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;
  • Arrange for the body to go to an accident and emergency department (rather than a mortuary) by ambulance, unless the circumstances of the death require the body to remain at the scene for forensic examination;
  • Prior to arrival at the accident and emergency department, provide relevant information and history to accident and emergency staff.
12.2.3 Where a child is not taken immediately to accident and emergency, 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
12.2.4  Accident and emergency staff and paediatricians on duty should be informed prior to the child's arrival at hospital, if that is not possible, then immediately the child arrives at hospital.
12.2.5 As soon as practicable (i.e. as a response to an emergency) after arrival at a hospital the baby or child should be examined by the consultant paediatrician on call (in some cases this might be together with a consultant in emergency medicine, or for some young people over 16 years the consultant in emergency medicine may be more appropriate than a paediatrician) and a detailed and careful history of events leading up to and following the discovery of the child's collapse should be taken from the parents. This should begin the process of collecting a nationally agreed data set.
12.2.6

On arrival at accident and emergency, staff should:

  • Establish the identity of those present and their relationship to the child;
  • Ensure that the parents are supported and kept informed;
  • 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 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;
  • Take 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.
12.2.7 Where the cause of death or factors contributing to it are uncertain, investigative samples should be taken immediately upon arrival and after the death is confirmed. These will need to be agreed in advance with the coroner and should 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) and standard sets for other types of death presentation as they are developed. 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.
12.2.8 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. 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).
12.2.9 The consultant paediatrician on duty must request and review all hospital records of the child and siblings and arrange for the records to be secured and available for the police as appropriate.
12.2.10 The consultant paediatrician on duty, in liaison with the police, should consider which other professionals may need to know. Individual cases will only need to be referred to the LA children's social care if the child is looked after, in receipt of current services from LA children's social care or if there are concerns about suspicious cause of death.
12.2.11 The consultant clinician on call must contact the designated paediatrician with responsibility for unexplained deaths in childhood immediately after the coroner is informed.
12.2.12 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
12.2.13 The professional confirming the fact of death should consult the designated paediatrician with responsibility for unexpected deaths in childhood who will ensure that relevant professionals (i.e. the coroner, police and LA children's social care) are informed of the death. This task may be undertaken by a person on behalf of the designated paediatrician. Contact may be required with more than one local authority if the child died away from home. Any relevant information identified by LA children's social care should be promptly shared with the police and on call paediatrician. The designated nurse and doctor for child protection should also be informed. They will contact the relevant GP, health visitor, school nurse or other relevant health professionals as a matter of routine practice in order that relevant information can be shared.
12.2.14 For all unexpected deaths of children (including those not seen in accident and emergency) urgent contact should be made with any other agencies who know or are involved with the child (including child and adolescent mental health services, schools or early years services) 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.
12.2.15 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.
12.2.16 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, LA children's social care) 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 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.
12.2.17 When a baby or older child dies unexpectedly in a non-hospital setting, the police senior investigating officer and senior health care professional should make a decision about whether a visit to the place where the child died should be undertaken. This should almost always take place for infants who die unexpectedly (See s5.1 Kennedy Report).
12.2.18 As well as deciding if the 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 (experienced in responding to unexpected child deaths and who may be a paediatrician) 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 (details should be included in the local child death review protocol).
12.2.19 After this visit, the senior investigating police officer, visiting health care professional, GP, health visitor or school nurse and LA children's social care 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.
12.2.20 If there are concerns about surviving children in the household, the procedures set out elsewhere in these procedures should be followed. If there are grounds for considering initiating a serious case review, the process set out in section 19. Serious case reviews should be followed.
12.2.21 The designated paediatrician should complete a report based on the history taken in accident and emergency, their home visit and a scrutiny of all available records, usually within 72 hours and prior to the post mortem.
12.2.22

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.
12.2.23 All professionals should provide all the above information and, where applicable, any suspicions must be provided to the receiving doctor and the police immediately.
12.2.24 The comments of parents must be noted in detail.
12.2.25 Anyone who contributes to the written records must legibly sign, date and put their designation / role.


12.3


Care of Parents/Family Members
12.3.1 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.
12.3.2 There should be arrangements for an identified professional to provide similar support to families where the child has not been taken to a hospital.  
12.3.3 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.
12.3.4 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.


12.4


The Involvement of the Coroner and Pathologist
12.4.1  All LSCBs should have a joint working protocol in place with their local coronial service. The paediatricians and the coroner should work closely and their meeting should be part of their induction week when they take up a new appointment. Coroners must be consulted over the local implementation of national procedures and protocols, along with the paediatrician colleagues, and should be asked to give general approval for the measures agreed so as to reduce the need to obtain specific approval on each occasion.
12.4.2 Once the child has been declared dead the coroner has jurisdiction over the body and all that pertains to it. The coroner must be consulted regarding the taking of mementos and medical samples. Where the death may be unnatural or the cause of death has not yet been determined the coroner will in due course hold an inquest.
12.4.3  In almost all cases, the coroner will order a post mortem to be carried out by the most appropriate pathologist. This may be a paediatric pathologist, a forensic pathologist or both, if concerns are identified before or during the post mortem.
12.4.4 Information collected by those involved in responding to the child's death should be collated by the designated paediatrician who then shares it with the pathologist conducting the post mortem in order to inform this process.
12.4.5 The post mortem must be conducted according to the guidelines laid down by the Royal College of Pathologists.
12.4.6 The coroner's office must ensure that all those they determine to be relevant are informed of the time and place the post mortem will be conducted and the interim or final findings should be provided immediately the post mortem is completed.
12.4.7 All information collected relating to the circumstances of the death including a review of all relevant medical, social and educational records (and concerns) must be included in a report for the coroner. The report is to be delivered to the coroner within 28 days of the death unless some of the crucial information is not yet available.
12.4.8 The coroner should provide the investigating officer with a full written report of the findings.


12.5


The Involvement of the Police
12.5.1 The police must be informed of all child deaths.
12.5.2 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.
12.5.3 A substantive detective sergeant, or above, must attend all scenes and a detective inspector must attend if there are suspicions of abuse or neglect.
12.5.4 The police child abuse investigation team (CAIT) 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.
12.5.5 The CAIT must be involved where there are any concerns for other children in the family / household.
12.5.6 A family liaison officer should be appointed to support the family.
12.5.7 Close liaison must be maintained throughout the investigation with coroner's office.
12.5.8 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.
12.5.9 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.


12.6


The Involvement of LA Children's Social Care
12.6.1 The duty manager must check records on notification of an unexplained child death. Notification will only have been made because of the absence of a satisfactory explanation giving rise to the possibility of suspicious circumstances.
12.6.2

If the child and/or family are known to children's services (open or closed case) other than merely through school attendance at a local or other school or registered day care provider, a manager must inform the child protection manager who must:

  • Secure the file;
  • Ensure that no additional recording or deletion occurs;
  • Inform the service manager, head of LA children's social care and the Director of Children's Services.
12.6.3 Subsequent recording must be on a new file.
12.6.4 If the child was in the care of approved foster carers, care staff, school staff or registered child minders 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 / CSCI respectively.
12.6.5 If the child and / or family is not known to LA children's social care, the duty / team manager must ensure that the relevant operational manager and the Director of Children's Services are informed.
12.6.6 The responsible manager must liaise with the designated paediatrician with responsibility for unexplained deaths in childhood and attend the multi-agency planning meeting or any strategy meeting / discussion (see 12.7 Multi-agency working).
12.6.7 Any child protection enquiry planned by the strategy meeting / discussion must be conducted within the child protection procedures framework.


12.7


Multi-agency Working

Multi-agency planning meeting
12.7.1 The designated paediatrician with responsibility for unexplained deaths in childhood must convene a multi-agency planning meeting within three days of the inexplicable death of a child.
12.7.2

The purpose of this meeting will be to:

  • 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 other previous child protection concerns;
  • Explain the paediatrician's understanding of cause of death, if they have one;
  • Consider if there are any child protection risks to siblings / any other children in the household;
  • Ascertain if a Strategy Meeting / discussion and s47 enquiry should be initiated for any surviving siblings;
  • Ensure a co-ordinated bereavement care plan for the family;
  • Consider who will visit the family to offer support and gather any further information;
  • Organise a review multi-agency meeting, when all information, including the post mortem report, will be available.
12.7.3 Where the death occurred in a hospital, the plan should also address the actions required by the Trust's serious incidents protocol.
12.7.4 Where the death occurred in a custodial setting, the plan should ensure proper liaison with the investigator from the prisons and probation ombudsman
12.7.5 If there is a possibility that the criteria for a serious case review might apply, the Chair of the LSCB should be contacted and the procedures for serious case reviews should be followed. See section 19. Serious case reviews.
12.7.6

At the initial planning meeting, a decision must be made as to whether the lead paediatrician will visit the family, alone or with the police, within 24 hours to:

  • Gather full information about the child, family and circumstances of death;
  • Explain the investigation process;
  • Offer support.


Participants to the multi-agency planning meeting
12.7.7

The following agencies may be included in the meeting:

  • Health: the designated paediatrician with responsibility for unexpected death in childhood, the doctor who certified death, the designated doctor and nurse for child protection, named health visitor, school nurse, GP and the consultant paediatrician responsible for the child;
  • LA children's social care: the responsible team / duty manager or their representative;
  • Police: CAIT and responsible unit for investigating the child's death (borough CID [in non-suspicious cases] and serious crime group Major Investigation Teams (MIT) in suspicious cases or when the child is subject to a Child Protection Plan).
12.7.8 Additional contributors may include the ambulance service, community midwife, school, nursery / pre-school. Legal advice should be sought as required.
12.7.9 If the child dies whilst in the care of a child minder or day care provider, or if the child concerned was the daughter / son of the child minder, Ofsted must be invited to the meeting. CSCI must be invited if the child died whilst in a registered children's home or family centre.

Case discussion following the preliminary results of the post mortem examination becoming available
12.7.10 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 paediatrician and pathologist, together with the senior investigating police officer, as soon as possible and the coroner should be immediately informed of the initial results.
12.7.11 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.
12.7.12 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 LA children's social care should be informed immediately and the serious case review processes in section 19. Serious case reviews also followed. If there are concerns about surviving children living in the household the procedures set out in section 6. Referral and assessment should be followed with respect to these children.
12.7.13 In all cases, the designated paediatrician for unexpected child deaths should convene a further multi-agency discussion (usually on the telephone) very shortly after the initial post-mortem results are available. This discussion usually takes place five to seven days after the death and should involve the pathologist, police, LA children's social care 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.

Case discussion following the final results of the post mortem examination becoming available
12.7.14 As soon as the final post mortem results are available, the designated paediatrician with responsibility for unexpected deaths in childhood should convene and chair a case discussion meeting, the timing of which will vary up to eight to 12 weeks after the death. Professionals involved in the meeting will include those who knew the child and family and those investigating the death.
12.7.15 The main purpose of the 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.
12.7.16 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.
12.7.17 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 offer them ongoing support
12.7.18 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 LA children's social care, 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.
12.7.19 An agreed record of the case discussion meeting and all reports should be sent to the coroner, to take into consideration in the conduct of the inquest and in the cause of death notified to the Registrar of Births and Deaths.
12.7.20 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.
12.7.21 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.


12.8


Child Protection Enquiry
12.8.1 If, at any point, there is a suspicion about the cause of death, child protection procedures must be initiated and a strategy meeting / discussion held regarding siblings and/or any other children who may be at risk of harm (as identified at the multi-agency planning meeting).
12.8.2 Child protection enquiries in respect of the death of a child will be led by the police as a major crime investigation. Where the welfare of other children is concerned, the joint working arrangements described in this manual for all procedures should be followed.
12.8.3 There are diverging views about the relevance of a previous unexplained death of an baby (normally under age two) within a family. Further to recent case law, practitioners should work on the understanding that the mere fact of a previous child death will not automatically lead to concerns about the means of death of a child or to further child protection concerns. Medical research into the area of sudden unexplainable deaths of infants continues and may come to re-shape this section of the child protection procedures. Practitioners in the meantime must maintain an open mind and use normal analytical tools in sifting relevant information as to determine likely risk of harm to other children in the future.
12.8.4 See section 18. LSCBs, quality assurance and conflict resolution for information on LSCBs' responsibilities for the child death review processes.

End