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2.5.1 Unexpected Death of a Child


Kent CDOP Unexpected Child Death Procedures

Medway CDOP Unexpected Child Death Procedures – to follow


In October 2017 this chapter was revised to make reference to the 2016 edition of Sudden unexpected death in infancy and childhood: Multi-agency guidelines for care and investigation (2e) (published by the Royal College of Pathologists and endorsed by the the Royal College of Paediatrics and Child Health). This updates the the previous (2004) edition.


  1. Introduction
  2. Scope
  3. Principles
  4. General Advice for All Staff
  5. Initial Action
  6. Initial Multi-Agency Communication / Rapid Response
  7. Visit Place of Death or Collapse
  8. Further Multi-Agency Discussion
  9. Post Mortem
  10. Discussion Following Preliminary Post Mortem Results
  11. Final Case Discussion Meeting
  12. Further Guidance

1. Introduction

As set out in the ‘Local Safeguarding Children Board Regulations 2006' LSCBs are responsible for putting in place procedures for ensuring that that there is a co-ordinated response by the local authority and its board partners and other relevant persons to an unexpected death of a child.

2. Scope

Chapter 5 of Working Together to Safeguard Children defines an unexpected death or a child less than 18 years old as one where: 

  • Death was not anticipated as a significant possibility for example, 24 hours before the death; or
  • There was an earlier 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 when professionals are uncertain if a death is ‘unexpected’ in terms of this procedure.

The designated paediatrician (or nominated substitute for periods when s/he is unavailable) is responsible for distinguishing between:

  • An ‘unexpected death’ that is explicable e.g. a road traffic accident; and
  • An ‘unexplained death’ which might have been anticipated as a significant possibility 24 hours before (hence not satisfying the formal criterion for ‘unexpected’ but may at the point of death be ‘unexplained’ e.g. a child’s whose health has been steadily deteriorating for no diagnosed reason for some weeks).

This procedure applies whether the child was in the care of a parent, hospital ward, foster carer, children’s home, boarding school, child minder, day care provider, hospital or any other carer.

If in doubt the processes for unexpected child deaths should be followed until the available evidence enables a different decision to be reached.

3. Principles

When dealing with an unexpected death of a child of any age, the following principles must be maintained:

  • Sensitivity, open mind and balanced approach;
  • Recognition of cultural needs;
  • An multi-agency approach involving working together and sharing of information;
  • Proportionate and appropriate response to the circumstances;
  • Preservation of evidence;
  • Good record keeping;
  • Congruence with specific requirements of local coroner;
  • Fast response and the need to conclude any enquiries or investigations expeditiously so the funeral is not delayed unnecessarily.

Police attendance should be kept to the minimum required and officers must be sensitive to the distress caused by uniforms, marked police cars, personal radios and mobile phones.

4. General Advice for All Staff

This is a very difficult time for everyone and though the time spent with the family may be brief, it could influence how relatives deal with the bereavement for a long time afterwards. The following points should be remembered:

  • The family are in the first stages of grief and may be shocked, numb, withdrawn or hysterical;
  • It is helpful to compile a verbatim and detailed initial account of events, including timings;
  • It is normal for a parent to want physical contact with her/his dead child and this should be allowed, albeit observed, except in exceptional circumstances to preserve evidence;
  • The child should be handled as if s/he were still alive and her/his name used at all times;
  • The impact of religious / cultural beliefs on parent/s responses;
  • The need to allow time for parents to ask questions, including where their child will be taken and when they are able to see her/him again;
  • Provision of written contact details to parents;
  • The possibility that there will be an inquest by a coroner to establish the circumstances of death;
  • The need for agency professionals to ensure they keep written records of the referral and subsequent contact.

5. Initial Action

The provision of medical assistance to the child is the first priority and an ambulance requested, unless already in attendance.

Ambulance Staff and GPs

Generally the ambulance service (or GP if first professional on the scene) should not assume death and thus should:

  • On receipt of a call regarding an unexpected child death the Ambulance Control Centre should contact the Police to inform them;
  • Try to resuscitate immediately (unless clearly inappropriate and the ambulance crew should consider this i.e. if the child has clearly been dead for some time); and then
  • If police are not already present, notify them and consult if the child’s body should be immediately transported to A&E – all children should be taken to A&E, unless the circumstances of death require the body to remain at the scene for forensic examination. There may be some situations where it is inappropriate for a children to be transferred to the hospital; including where a child has obviously been dead for some time when found and it has been agreed with the police that the child remain in situ until the scene has been examined. Also where the circumstances of the death e.g. when the death is suspicious or there are obvious signs of neglect/assault mean the body must remain at the scene for forensic examination; or there is significant trauma to the body as a result of fire or other major incident;
  • Arrange for the deceased child to go to A&E or children’s hospital by ambulance along with representatives of the family unless the family make their own arrangements to reach the hospital (or, if police decide it is not appropriate to move the body, the doctor confirming death must inform the designated paediatrician with responsibility for unexpected deaths in childhood);
  • Prior to arrival, provide relevant information and history to A&E.

If the child has clearly been dead for some time, attempted resuscitation may be inappropriate and a forensic medical examiner (FME), GP or qualified nurse may confirm the fact of death at home and inform the police (via the police control room) and coroner’s office. No certificate will be issued and following consultation with the police the baby / child should be taken to the mortuary for a post mortem.

The family should be taken to A&E to ensure receipt of appropriate medical and social support.

Professionals present should take note of the position of the child, clothing worn and circumstances of how the child was found, living conditions and any comments made by parents / carers.

Any information (including suspicions) should be passed onto the receiving hospital doctor and directly to the police.


The Police should attend and secure the scene to preserve it in case of forensic capture. The Senior Investigating Officer will visit at a later time, usually within hours, as their first action will be to visit wherever the deceased is and to link with the family and health.

The lead responsibilities within the Police for the investigation into the death of a child will be undertaken by:

  • A Senior Investigating Officer (SIO) from the Major Crime Department; If at the outset or subsequently there are indications that the death of a child raises suspicion of homicide;
  • A SIO from the Serious Collision Investigation Unit (SCIU); If the death results from a Road Traffic Collision;
  • Out of hours; In all other cases a SIO of Detective Inspector rank who will subsequently handover the investigation to the Public Protection Unit (PPU) Detective Inspector, if they are not already in attendance.

Hospital Staff

A&E staff must inform the consultant paediatrician or A&E consultant immediately of the arrival of the child & family and:

  • Attempt resuscitation (unless clearly inappropriate appropriate) according to the UK Resuscitation Guidelines (2015) until the paediatrician on call has decided to stop further efforts; A&E staff and the senior paediatric doctor will assess the child and make the decision to stop resuscitation;
  • Establish identity of those present and their relationship to the child;
  • In all cases allocate member of staff to remain with the parents / carers to support them through the process and keep them informed at all times (this may be the consultant paediatrician or an experienced A&E nurse);
  • Check that the police have been notified (via the police control room) if the child is dead on arrival or subsequently dies;
  • Undertake checks with Local Authority Children’s Services.

As soon as possible after arrival at the hospital the consultant paediatrician on call should undertake the initial examination (the consultant in emergency medicine may also need to be involved and for children over 16 years, may be more appropriate). The paediatrician should undertake a full general examination in the presence of the police and:

  • Report on injuries, rashes and observations about the child’s physical condition;
  • Record site and route of any intervention in resuscitation;
  • Establish a detailed and careful history from the parents of events leading up to and following the discovery of the child’s collapse;
  • Obtain a full medical and family history, including siblings, history of other child deaths and medical concerns;
  • Inform the police immediately if injuries or concerns noted;
  • Ensure personal mementos, clothing or bedding are not removed prior to consultation with coroner and police (there should be a clear audit trail evidencing who has taken property, when and where it can be found);
  • Allow parents to see and hold their child, with discreet supervision, both in the hospital and in the mortuary;
  • Speak directly to the coroner’s office;
  • Consideration of a full skeletal survey in consultation with the pathologist (this should be undertaken prior to the autopsy as may significantly alter the required investigations). If the death is being treated as suspicious, a police photographer should take photographs.

The Kent coroner has given permission to Consultants within the hospital for samples to be taken from children under one year whose death is unexpected, without the need for prior discussion with the coroner.

When the child is pronounced dead the consultant paediatrician on call must inform the designated paediatrician with responsibility for unexpected deaths in childhood and agree which of them will:

  • Request and review all hospital records of the child and siblings, and arrange for them to be photocopied for the Police;
  • Inform the parents of the death and the known medical facts (this should be in the privacy of an interview room, but in the presence of the member of staff allocated to support the family);
  • Information about what will happen to their child’s body including taking samples, post mortem, release of the body for funeral, arrangements to re-visit and take mementos from their child (hand and footprints etc);
  • Explain to parents that the coroner must be informed to decide if a post mortem will be necessary to try to discover cause of death;
  • Provide information on the post mortem process, including a leaflet and parents rights to be represented at the post mortem by a medical practitioner of their choice, provided they have notified the coroner (Coroners’ Rules 1984);
  • Explain to parents that Police will be involved and Local Authority Children’s Services records checked as a matter of routine and a home visit made Parents should be requested not to disturb the room in which the child died until a home visit is carried out;
  • Introduce Police to parents if lead investigator already at the hospital;
  • Provide information and details of support agencies local and national e.g. leaflets published by the Foundation for the Study of Infant Deaths;
  • The next steps in the child death review process e.g. MSCB Leaflet “The Child Death Overview Panel Information for parents”;
  • Contact information for relevant professionals who will have on-going involvement with the investigation of their child’s death.

The comments of parent / carers should be noted in detail. Parents / carers should not be left unsupervised with the child’s body – staff should maintain a discreet presence.

Anyone who contributes to the written records must legibly sign, date and put her/his designation / role.

6. Initial Multi-Agency Communication / Rapid Response

As soon as possible after the child’s arrival at A&E confirmation of the child’s unexpected death the coroner and Police must be informed if not previously informed.

The paediatrician on call / designated paediatrician with responsibility for unexpected deaths in childhood must initiate the rapid response process and hold a multi-agency information sharing and planning discussion/s (by phone and/or meeting) with lead agencies involved within 24 hours of the death or on the first working day following the death i.e:

  • The Coroner’s office must be informed, if not already. The Coroners (Investigations) Regulations 2013 place a duty on coroners to inform the LSCB, for the area in which the child died or the child’s body was found, where the coroner decides to conduct an investigation or directs that a post mortem should take place. The coroner must provide to the LSCB all information held by the coroner relation to the child’s death. Where the coroner makes a report to prevent other deaths, a copy must be sent to the LSCB;
  • Police must be contacted and arrangements made for the officer designated to lead the investigation to be introduced to the parents whilst they are at the hospital (if possible) and talk to the parents jointly with the paediatrician at the home visit;
  • Local Authority Children’s Services should be contacted (possibly more than 1 authority if the child died away from home) and its records checked: the relevant paediatrician should communicate directly with the duty / allocated social worker if the family are known;
  • The child’s GP, health visitor and school nurse (if applicable) should be contacted as soon as possible to ensure they are fully informed and to obtain relevant information;
  • Any other relevant professionals / agencies;
  • The local LSCB child death review coordinator must be informed of any deaths in the locality.

If the death occurred in a hospital, the plan should also address the actions required by the Trust’s serious incidents protocol.

If the death occurred in a custodial setting, the plan should ensure appropriate liaison with the investigator from the Prisons and Probation Ombudsman’s office.

For all unexpected deaths (including those not seen in A&E) urgent contact should be made with any other agencies who know or are involved with the child including CAMHS, school, early years services to ensure they are informed and to obtain relevant information on the child, the family and other members of the household.

If significant concerns are raised at these discussions about the possibility of neglect or abuse, the police should become the ‘lead agency’ and immediately a formal crime scene investigation at the site of the child’s collapse or death. At this point the normal child protection procedures must be followed and a Section 47 Enquiry initiated about any surviving siblings.

7. Visit to Place of Death or Collapse

At the discretion of the senior investigating officer, Police may visit the scene of death immediately, and before discussion with parents.

The senior investigating officer and senior health care professional should make a decision about whether to visit the place the child died or collapsed, if this occurred outside of the hospital. For infants who die unexpectedly this should almost always occur (see Paragraph 5.1 in ‘Sudden unexpected death in infancy and childhood: Multi-agency guidelines for care and investigation (2e)” (published by the Royal College of Pathologists and endorsed by the the Royal College of Paediatrics and Child Health)).

Within 24 hours of the death, the designated paediatrician for unexpected child deaths (or alternative senior health professional experienced in responding to unexpected child deaths) and senior police investigating officer should undertake a joint home visit (or to the place where the child collapsed / died if different) to:

  • Explore the circumstances of the death, relevant events and previous history;
  • Carry out a systematic examination of the site of the child’s death.

If a joint visit is impossible within this time, separate visits should occur.

The family’s GP and health visitor could usefully be included in this meeting and should ensure arrangements are quickly put into place for appropriate bereavement support.

The Coroner’s Office should be informed of the visit and information provided to parents about Coroner’s procedures.

It must be explained to parents that this is a routine part of the investigation to help identify and understand the factors that have contributed to the death and contribute information for the pathologist, prior to the post mortem examination.

Arrangements should be made to ensure that the scene of the child’s collapse and / or death is left undisturbed until the visit takes place.

8. Further Multi-Agency Discussion

Following this visit to the scene of the collapse / death, the designated paediatrician for unexpected child deaths, senior investigating police officer, health visitor and GP should review the findings.

If significant concerns about the possibility of abuse or neglect have been newly identified, Local Authority Children’s Services should convene a Strategy Discussion and initial Section 47 Enquiries on any surviving siblings and the police should (if not already initiated) institute a ‘crime scene investigation’. Consideration should be given the appropriateness or not of holding a Serious Case Review (see Kent Learning and Improvement Framework).

9. Post Mortem

The post mortem examination will be ordered by the coroner, and should be carried out as soon as possible by the pathologist, who will perform the examination according to the guidelines and protocols laid down by The Royal College of Pathologists. The most appropriate pathologist in order of preference and according to the circumstances should be a:

  • Forensic Paediatric Pathologist;
  • Forensic Pathologist working alongside a Paediatric Pathologist;
  • Forensic Pathologist;
  • Paediatric Pathologist.

The designated paediatrician for unexpected child deaths should fully brief the pathologist/s by presenting the collated information collected by those involved in responding to the child’s death.

The post mortem should routinely involve a full radiological skeletal survey, reported on by a radiologist with paediatric training and experience.

If the death is deemed to be unnatural, or the cause not yet determined, the coroner will hold an inquest.

The paediatrician’s report to the coroner should review all relevant medical, social and education records, clinical circumstances of the death and the history obtained at the home visit. This report should be delivered to the coroner within 28 days of the death, unless some critical information is not yet available.

The Kent and Medway Coroner has agreed for the release of the post mortem results to the Child Death Review Coordinator.

10. Discussion Following Preliminary Post Mortem Results

The preliminary results of the post mortem belong to the commissioning coroner. The pathologist should discuss these, as soon as possible, with the designated paediatrician and senior investigating police officer and the coroner immediately informed of the initial results.

If the post mortem findings suggest evidence of neglect or abuse:

If this is not the case, the designated paediatrician for unexpected child deaths should communicate the findings to the primary care team and the family, although the police may wish to be involved in the process.

In all cases there should be a further multi-agency discussion (usually by phone) involving pathologist, Coroner’s officer, Police, Local Authority Children’s Services, designated paediatrician for unexpected child deaths and other relevant healthcare professionals to discuss the post mortem findings and ensure no additional information has emerged relevant to safeguarding issues. This should occur within 5 to 7 days after receipt of the post mortem findings.

11. Final Case Discussion Meeting

The designated paediatrician for unexpected child deaths should convene and chair a case discussion meeting as soon as possible after the final post mortem result is available (timing will vary according to circumstances, but should be no more than 8 to 12 weeks post death).

The meeting, usually in the hospital / health centre / GP surgery, should include professionals who knew the child / family and those involved in investigating the death i.e. GP, health visitor / school nurse, paediatrician/s, pathologists, senior police investigating officer and where appropriate Local Authority Children’s Services. The coroner or coroner’s officer will be involved and may choose to attend the meeting, or may agree to the police attending as both the investigating agency and the coroner’s representative.

At this stage the collection of core data should be completed and, if necessary, previous information corrected in a manner consistent with enabling the change to be audited.

The purpose of the meeting is to:

  • Share and review information;
  • Identify factors that contributed to the death;
  • Explicitly comment on the presence or not of concerns about abuse and neglect causing or contributing to the death – if no evidence of maltreatment this should be clearly documented;
  • Explicitly comment on the quality of medical and social care and consider potential lessons to be learnt;
  • Share/discuss reports for the Child Death Overview Panel;
  • Agree how detailed information about cause of death will be shared with the parent, by whom and who will offer ongoing support.

Families are not ordinarily invited to the meetings, but should be fully informed of the outcome at the earliest opportunity, usually at a meeting with the designated paediatrician for unexpected child deaths or the paediatrician responsible for the child’s care and a member of the primary health care team. The parents should also be provided with written information on the outcome.

If abuse is suspected and/or the police are conducting a criminal investigation, the paediatrician should discuss with police and Local Authority Children’s Services what information should be shared, how and when.

The designated paediatrician for unexpected child deaths is responsible for providing an agreed record of the meeting and all reports to the coroner. The coroner will take this into consideration in the conduct of the inquest and in cause of death notified to the Registrar of Births and Deaths.

The summary of the case discussions and the record of the core data set should be made available to the Child Death Review Panel when the child dies away from their residential area.

12. Further Guidance

The Lullaby Trust produces a range of leaflets and information for families and professionals (telephone: 020 7235 1721).

 “Babyzone” is a leaflet for parents on how to keep baby safe and healthy but is an excellent tool for professionals.

See also ‘Sudden unexpected death in infancy and childhood: Multi-agency guidelines for care and investigation (2e)” (published by the Royal College of Pathologists and endorsed by the the Royal College of Paediatrics and Child Health)

Medway has produced a “Professional’s Safer Sleeping Prompt Card” and “Parent’s Temperature Advice Thermometer”.