Chapter Eighteen

Child Death Overview Procedures

In this section:

Introduction
Context
Core Purpose
Membership
Frequency of CDOP Meetings
Notification of Child Deaths
Deaths of Children out of area
Key Functions
Consent and Confidentiality
Professional and Family Support
Learning from Child Deaths
Reporting Mechanisms
SUDIC Response to unexpected deaths procedure

Appendix 1:LLR SUDIC flowcharts

Appendix 2:DCSF Templates

Appendix 3:Leaflet for parents

Appendix 4:Consent form

Appendix 5:Terms of reference

Appendix 6:Threshold criteria

Appendix 7:CDOP Contact Details including Agency SPOC’s

Appendix 8:Information Sharing Agreement

Appendix 9:Confidentiality Agreement

Note: Other Appendices to be tabled

Introduction

18.1 This Procedure sets a minimum standard for the Leicester, Leicestershire and Rutland (LLR) Child Death Overview Panel (CDOP) as outlined in chapter 7 of the Government guidance Working Together to Safeguard Children (DCSF, 2006) (Working Together) for the review of all deaths.

If the death is unexpected please refer to LLR SUDIC Response Process (section 18.13)

18.1.2 As described in Working Together and the Local Safeguarding Children Board Guidance (DCSF, 2006), there are two inter-related processes for reviewing child deaths. Either process can trigger a serious case review.

18.1.3 The processes are:

  • An overview of all child deaths (birth up to 18th birthday, excluding babies stillborn) in the LLR LSCB area undertaken by a panel drawn from key organisations represented on the LLR LSCB.
  • A rapid response by a team of key professionals who come together for the purpose of enquiring into and evaluating each unexpected death of a child, this is detailed in the LLR SUDIC Response Process (LSCB, 2008).

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18.2. Context

18.2.1 When a child dies within the LSCB area in which they normally reside, the LLR LSCB must collect and analyse information about each death with a view to identifying:

  • any case giving rise to the need for a review mentioned in Regulation 5(1) (e) of the Local Safeguarding Children Board Regulations 2006;
  • any matters of concern affecting the safety and welfare of children in the area of the authority; and
  • wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area.

18.2.2 Where the Panel is made aware of the death of a child in their area who would normally be resident in another Local Authority (LA) area, or the death of a child in another LA area who would normally be resident in their area, the Child Death Review (CDR) Manager will liaise with their colleague in that area to ensure both Panels are notified of the death and to determine which Panel will be best placed to carry out the review of the child’s death.

In all situations the CDR Manager will have the responsibility of ensuring appropriate communication takes place and that the CDOP Panel is regularly updated as to circumstances and timescales.

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18.3. Core purpose

18.3.1 The CDOP will undertake an overview of all child deaths within the LLR LSCB locality. This process will use the DCSF National Data Templates based on information available from those who were involved in the care of the child, both before and immediately after the death, and other sources.

The CDR Manager will have overall responsibility in ensuring that on receipt of the CDOP Form A Notification Of Child Death Form that all agencies / professionals who have been identified as having contact with the child or family are sent a CDOP Form B Agency Report Form for completion via each agency Single Point of Contact (SPOC) for completion and timely return.

18.3.2 The CDOP has responsibility for reviewing the deaths of all children, with priority given to those deaths that are both unexpected and unexplained. In all cases the LLR LSCB SUDIC Response Process (SRP) will be followed with particular reference to the LLR SRP Flowchart.

18.3.3 If information emerges which requires the LSCB Chair to request a Serious Case Review (SCR) in relation to the death of a child (in line with chapter 17) the SRP will be halted. The CDR Manager will maintain close links with the respective agencies and ensure the CDOP Chair is kept informed. Upon completion of the SCR a summary will be forwarded to the CDR Manager to be included in discussion at Panel.  

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18.4. Membership

The membership of the CDOP Panel will be reviewed on a regular basis.

18.4.1 There will be a fixed core membership on the CDOP, which is drawn from the key organisations represented on the LLR LSCB. The minimum should be senior management representation from:

  • Public Health [Chair]
  • Leicester Constabulary CAIU
  • Leicester City & South Leicestershire Coroner
  • CDR Manager
  • CDOP Secretary
  • Leicester City Council CYPS
  • Leicestershire CYPS
  • Rutland CYPS
  • Leicester City Community Health Service
  • University Hospitals of Leicester
  • SUDIC Paediatrician

18.4.2 Other members will be co-opted as and when appropriate, so that the membership of the CDOP better reflects the characteristics of the local population, to provide a perspective from the independent or voluntary sector or to contribute to the discussion of certain types of death e.g. Neonatal Consultant, Leicester Council of Faiths, Leicestershire Fire & Rescue Service, Adult Mental Health Services, Child and Adolescent Mental Health Services, Rainbow’s Children’s Hospice, Diana Palliative Care Services, Bereavement Services etc.

18.4.3 The CDOP Chair will be a senior representative from Leicester City or Leicestershire County and Rutland Primary Care Trust’s Public Health directorate.

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18.5. Frequency of CDOP meetings

18.5.1 The CDOP will meet monthly for 3 hours to enable the circumstances of each child death to be discussed in a timely manner.

The cases to be discussed at each panel meeting will be identified following discussions by the CDR Manager and SUDIC Dr. This may include identification of themes and patterns.

The CDR Manager will be responsible for ensuring case material is distributed to panel members one week in advance to ensure that there is adequate panel preparation time. Panel members will acknowledge receipt of case material.

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18.6. Notification of child deaths

18.6.1 The LLR LSCB CDOP office based in Leicester City Community Health Services of Leicester City PCT, based at Beaumont Leys Health Centre will be informed of all child deaths (expected and unexpected) in the LLR LSCB area, regardless of whether the child is resident in the area.  Notification can be received from any professional or agency single point of contact (SPOC) who becomes aware that a child has died via either

  • Secure Haven Fax: 0116 2958712
  • Telephone: 0116 2958724

Monday – Friday 9am – 5pm

18.6.2 Expected Deaths
Notification should be given to the CDR Manager within 24 hours or next working day. In addition to standard notification protocols a CDOP Form A will need to be completed and forwarded to the LLR LSCB CDOP office (see 18.6.1).
The CDOP office will inform Health, Births and Registrations, LA Children’s Social Care and Education and where relevant HM Coroner.  Further information will be collated by the CDR Manager who will contact agencies to complete and return CDOP Form B Agency Report Form to CDOP Secure Haven Fax (see 18.6.1).  A Summary Report (CDOP Form C Analysis Proforma) will be forwarded to the CDOP Panel for discussion, coordinated by the CDR Manager.  Ongoing support to the family will be assessed, managed and reviewed.

The Maternity and Neonatal Services within University Hospitals of Leicester will forward a copy of the CEMACH form instead of the DCSF CDOP Form B in respect of all child deaths under the age of 28 days, and forward to the CDOP office as detailed above.

If the child was known to have a life limiting condition there should be prompt communication with the palliative care team to ascertain that the death was indeed expected.

18.6.3 A list of all Agency SPOC’s is maintained by the CDOP office.

18.6.4 CDOP Documentation Process for Expected Deaths

Following notification of the expected death of a child the CDOP office will request completion of CDOP Form A. This is to be returned to the CDOP office within 1-2 working days.

The CDR Manager may then request additional information from relevant agencies. All contact will be via the SPOC or agreed contact (e.g. where information is requested from a GP) to be compiled on CDOP Form B and subsections B2-10 as required. A request for information will be sent within 1-2 working days.

CDOP Form Bs are to be returned completed with as much information as possible within 10 working days. At the discretion of the CDR Manager CDOP Form Bs may be returned to agencies with a request for additional information.

If agencies do not return the documentation within the requested timescales the CDR Manager will take further action.

CDOP Form C will be completed by the CDR Manager aided by relevant parties as required.

The case will be taken to Panel within 12 weeks or nearest available Panel date to this time.

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18.7. Deaths of children out of area

18.7.1 Where a child who normally lives in the LLR area, dies outside the LLR boundary, it is expected that the CDOP office for the area in which the child died will inform the LLR CDOP office of the death and its circumstances (see 18.2.2).

18.7.2 Information sharing between two CDOP’s when a child dies out of their normal residency area is in addition to informing HM Coroner within 1 working day.

18.7.3 The CDR Manager is responsible for ensuring that this process operates effectively.

18.7.4 In respect of children who die in hospital, if the death is felt to be expected the death should normally be reviewed by the CDOP for the area in which they lived.  

18.7.5 The CDOP must review the circumstances of children who are normally resident in the area but who die abroad. If the CDOP office is informed of a child’s death abroad a discussion will take place between the SUDIC Dr, CDR Manager and CDOP Chair to discuss and agree how this death will be managed.

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18.8. Key functions

The Child Death Overview Panel will:

  • Meet regularly to complete a multi-agency evaluation of all child deaths in their area;
  • Where appropriate undertake a detailed and in-depth evaluation into specific cases, including all unexpected deaths, assessing all relevant social, environmental, health and cultural aspects, or systemic or structural factors of the death, along with the appropriateness of the professionals’ responses to the death and involvement before the death, in order to complete a thorough consideration of whether and how such deaths might be prevented in future;
  • Collect and collate information using the locally agreed templates (DCSF, 2008) and where relevant seek further information from professionals and family members;
  • Identify local lessons and issues of concern, requiring effective inter-agency working;
  • Identify and report any local 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;
  • Identify and advocate need for changes in legislation, policy and practices, or public awareness, to promote child health and safety and to prevent child deaths;
  • Ensure concerns of a criminal or child protection nature are shared with the Police, Children’s Social Care and the Coroner;
  • Ensure any case identified as meeting criteria for a Serious Case Review are referred to the Chair of the LSCB;
  • Provide information to professionals involved with families so that this can be passed on in a sensitive and timely manner;
  • Implement, review and monitor the local procedures for rapid response arrangements in line with Working Together 2006;
  • Monitor the quality of information, support and assessment services to families of children who have died
  • Co-operate with any regional and national initiatives in order to identify lessons on the prevention of child deaths.

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18.9. Consent and confidentiality

18.9.1 Information within CDOP Panel meetings will be anonymised.

18.9.2 Standard data collection does not require parental consent for this information to be passed to the SUDIC Dr / LSCB CDOP office. It should only be shared with those who need to know as governed by the Caldicott Principles, the Data Protection Act and Working Together.

If further information is required by accessing additional family records to inform the review then the person(s) with parental responsibility (Children Act 198)] should be advised that the child’s death will be subject to a review in order to learn any lessons that may help to prevent future deaths of children. In these circumstances informed consent will be obtained using the CDOP Consent Form.

This must be handled sensitively. It should normally be done by the Named Nurse whilst undertaking a visit, or other lead professional and will be followed up with a letter from the CDR Manager approximately two weeks following the child’s death. In addition the family will be offered an LSCB CDOP leaflet available to assist parents and others with parental responsibility in understanding the review process and how they can contribute which may be given whilst the family are in the Emergency Department (A&E) or during the visit undertaken by the Named Nurse.

18.9.3 An Information sharing agreement has been developed to be signed by all LLR LSCB member agencies to ensure professionals are aware of information sharing requirements to enable the LSCB to carry out its statutory duty.

18.9.4 Members of the CDOP must sign a confidentiality agreement, including sharing and securely storing information when they join the CDOP Panel. This agreement will be reviewed at each meeting.

18.9.5 In no case will any Panel member disclose any information regarding Panel discussions outside the meeting, other than pursuant to the mandated agency responsibilities of that individual. Public statements about the general purpose of the child death review process may be made, but must be agreed with the CDOP Chair in advance.

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18.10. Professional and family support

18.10.1 Before the CDOP meets, the CDR Manager should ensure that explanatory information has been sent to the child’s family.

18.10.2 The CDOP Chair should consider what feedback is given to those professionals involved with the child’s family so that they, in turn, can convey this information in a sensitive and timely manner to the family. If requested by the family a meeting will be arranged with the CDOP Chair or CDR Manager to meet with them to offer appropriate and sensitive feedback.

It is important to recognize the emotional impact on staff involved with families where a child has died. All staff should have access to appropriate support within their own agencies.

18.10.3 The CDOP Chair should ensure that information is also received and evaluated by the CDOP regarding the services and immediate support offered to the families of children who have died.

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18.11. Learning from child deaths

18.11.1 The CDOP should monitor and advise the LLR LSCB on the resources and training required locally to ensure an effective inter-agency response to child deaths.

18.11.2 The CDR Manager will maintain an audit trail of all recommendations made and actions undertaken.

18.11.3 The CDOP should identify any public health issues and consider, with the Director(s) of Public Health, how best to address these and their implications for both the provision of services and for training.

18.11.4 The CDOP should contribute to regional and national initiatives to identify lessons on the prevention of unexpected child deaths e.g. CEMACH, DCSF.

18.11.5 Following the production of a six monthly report, the SPOC within each agency will liaise with the CDR Manager to advise of measures undertaken to ensure Panel recommendations have been actioned.

18.11.6 The six monthly report will be sent to the CEO and Governance Officers within each agency for dissemination to staff.

18.11.7 At agreed timescales the CDR Manager will facilitate study days to allow for update on the CDOP process and overview of lessons learnt.

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18.12. Reporting mechanisms

18.12.1 CDOP is a sub committee of the LLR LSCB and therefore required to submit an annual report to the LLR LSCB.

CDOP will also contribute to the Directors of Public Health annual reports.

18.12.2 The LLR LSCB is responsible for:

  • Disseminating the lessons to be learnt to all relevant organisations;
  • Ensuring that relevant findings inform the Children and Young People’s Plan and that there is close liaison with The Childrens Trusts;
  • Ensuring recommendations are acted upon to improve policy, professional practice and inter-agency working to safeguard and promote the welfare of children; and
  • Ensuring that data relating to child deaths is submitted to relevant regional and national initiatives to identify lessons on the prevention of unexpected child deaths.

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18.13 Responding to the unexpected death of a child

Introduction

These procedures set a minimum standard for responding to unexpected deaths in infancy and childhood as outlined in chapter 7 of the Government guidance Working Together to Safeguard Children. They should be followed when:

  • A decision is made that the death of the child is unexpected, or
  • There is a lack of clarity about whether the death of the child is unexpected

An unexpected death is defined as:

‘any child whose death was not anticipated as a significant possibility 24 hours before the death occurred, or where there was a similarly unexpected collapse leading to or precipitating the events which led to the death’.

  • traffic accidents, suicides and murders, and any sudden unexpected/unexplained death in infancy childhood.
  • the unexpected death of a child who has a life-limiting condition but whose death was not anticipated within the previous 24 hours,
  • any child admitted to a hospital ward and who subsequently dies unexpectedly in hospital.

For expected deaths, e.g. if an attending doctor is able to sign the death certificate, please see section 18.6 above.

18.13.2 If Concerns develop that the death may be suspicious:

Significant concerns may be raised at any stage during these procedures by family members, or from any of the involved agencies, that neglect or abuse may be a cause of the child’s death. If this happens LLR Child Protection Procedures will be followed. A verbal referral to the Police /Childrens Social Care will be made immediately, and confirmed in writing detailing the circumstances and nature of these concerns (see LSCB procedures chapter 5).

a)  If the Police decide that the death is now a matter for criminal investigation the balance of responsibility moves away from the healthcare professionals and the Police will take the lead role. Professionals may be required to provide statements.


b)  In cases where the death is now under criminal investigation the SRP will be halted. The CDR Manager will maintain regular contact with the Police regarding developments. If there is insufficient evidence to pursue a criminal investigation the SRP procedure may be reinstigated at an appropriate phase, following discussion with the CDR Manager, SUDIC Dr and Police.


c)  If there are other children in the household, or children who have significant contact with the family and suspicion develops at any stage that the death may be caused by neglect or abuse, child protection enquiries must also be instigated (see chapter 5). Childrens Social Care must be fully involved and take the lead in considering whether other children within the household need immediate protection.


d)  In all cases where emerging concerns around child protection are identified, the SUDIC Dr must consult with relevant agencies and the CDR Manager and decide whether there is a need for an immediate strategy meeting (s47) or whether this can wait until the initial findings of the post mortem. This MAY take the place of an initial case discussion within the SRP led by the SUDIC Dr.


e)  If information emerges which requires the LSCB Chair to request a SCR in relation to the death of a child (in line with chapter 17) the SRP will be halted. The CDR Manager will maintain close links with the respective agencies and ensure the CDOP Chair is kept informed. Upon completion of the SCR a summary will be forwarded to the CDR Manager to be included in discussion at Panel.  

18.13.3 These procedures recognise the duty of care multi-agencies have to process communication, undertake collaborative action and information sharing following the unexpected death of a child, thereby achieving a safe, consistent and sensitive response to families. In particular, they are intended to:

a)  enable the capturing of immediate information about unexpected child deaths with an open minded and balanced approach.

b)  ensure opportunities for information gathering are not lost.


c)  collate information in a standard format.


d)  bring together relevant agencies to assess the information in an evidence based and measured manner, and evaluate the reasons for and circumstances for the death, in agreement with HM Coroner.


e)  engage agencies appropriately post death, maintaining contact at regular intervals with family members and other professionals who have ongoing responsibilities to the family, to ensure that they are appropriately informed and supported.

18.13.4 The 3 Phases within the SUDIC Response Process:

There are three distinct phases within these procedures describing the processes of communication, collaborative action and information sharing. These should be applied following the unexpected death of a child. In each of the 3 phases HM Coroner will be consulted and kept informed by the SUDIC Dr and Police as appropriate. HM Coroner assumes responsibility for the child’s body and will decide which pathologist will complete the post mortem examination where relevant.

Phase 1: Initial enquiries: The collaborative process between the attending physician, SUDIC Dr and DI on call in which a decision is made as to whether a child’s death is expected or unexpected.

Phase 2: Case discussion meeting: (5-7 days) A multiagency meeting which ensures that all agencies are informed and updated, that any concerns are identified and appropriately managed and detailed in resultant action plans.

Phase 3: Review: (20-26 weeks) This review identifies or confirms the cause of death and / or contributory factors at the point when the final post mortem report is available. This review also considers the future care for the family.

Issues to be considered throughout all 3 Phases are:

a)  The needs of the bereaved family should be taken into account at every stage. This includes the welfare and protection of remaining siblings, spiritual needs and possible involvement of the extended family.

b)  Any religious or cultural beliefs which may have an impact on these procedures should be taken into account. Issues must be dealt with sensitively, whilst maintaining a consistent approach to the procedure.

c)  It is important to recognise the emotional impact on staff involved with families where a child has died unexpectedly. All staff should have access to appropriate support within their own agencies.

d)  In certain circumstances a child’s death may generate media interest and practitioners may be contacted by the media. In all cases practitioners should follow their own agency communication strategy and refer the enquirer to the appropriate agency Department. In all cases the CDOP Chair will be advised of relevant actions undertaken by the agency involved via their SPOC.

e)  In high profile cases media attention and enquiries will be managed by the LSCB in collaboration with the Police and relevant Trusts / Agency Press officers.

 

Practical Procedures for implementing the SUDIC Response Process


18.13.5 Phase 1: Initial enquiries

Role of the first professionals on the Scene

If the first professionals on the scene are not medical professionals, they must obtain urgent medical assistance as the first priority. Following the receipt of a call to the East Midlands Ambulance Service (EMAS) Control Centre the nearest available Emergency Response will be sent to the scene as detailed in Clinical Guidance Bulletin 51.

 

Police

The Police will be informed and will attend in the majority of unexpected deaths from the outset.  They are typically called with the other emergency services to most deaths and serious injuries.

Police officers attending the scene of any death will be following the Leicestershire Constabulary Procedure for the Investigation of Sudden, Unexpected and Questionable Deaths. In cases involving the unexpected death of a child the attending officer[s] will make contact with the Detective Inspector on Call for support and advice.

If the death is not thought to be suspicious then the officers will act on behalf of HM Coroner to record and report all material evidence and information

 

East Midlands Ambulance Service (EMAS)

a)  On arrival the child will be assessed with a Primary Survey and if required Advance or Intermediate Life Support (UK Resuscitation guidelines 2005) will be commenced with immediate transport to the nearest A&E with a hospital alert call of expected time of arrival. Nothing in this procedure should interfere with the absolute priority of effective resuscitation if this is possible.

b)  The EMAS crew attending will observe the scene and position of the child on arrival and include these details on their Patient Report Form (PRF) as this may be crucial to the process of making sense subsequently of the circumstances of the death.

c)  If following the primary survey and all checks for signs of life combined with the history of events the infant / child is obviously dead the crew at the scene will liaise with the Police.

d)  Arrange for the child to be taken immediately to the A&E rather than to a mortuary whether or not the child is self evidently dead.

e)  If there are clear signs which give rise to suspicions around the circumstances of the death the Police may request the body to remain at the scene for forensic examination. The crew will await the arrival of the DI on call who will make the decision if the scene is a crime scene. In this case the child will be left at the scene and the DI on call will sign the PRF accordingly.

f)  Prior to arrival at A & E the crew will forward relevant information and history to the waiting medical staff.

g)  A copy of the PRF, Diagnosis of Death and Registration of End of Life Care Decision documentation where relevant will be faxed to the CDR Manager.

 

General Practitioners

There are times when a GP is called to the child first. In such circumstances the GP should adhere to the same principles as EMAS (see above).

It is essential for the GP to contact the Police or HM Coroner’s Officers if they are first on the scene, after taking into account their primary responsibility of saving life or declaring death. In these circumstances a GP may not issue the death certification, if the death is felt unexpected.

The GP will complete a DCSF CDOP Form A Notification of Child Death and where appropriate DCSF CDOP Form B Agency Report Form and forward to the CDR Manager.

 

Emergency Department and Other Hospital Settings

The first priority as in any such case will be the provision of medical assistance to the child.

As soon as practicable, the child should be examined by the attending doctor, Consultant Paediatrician or deputy.

The parents will be allocated a specific member of staff to provide support, advice and care with relevant details recorded in the child’s records. Any relevant information by parents/carer about the circumstances of the death must also be recorded in writing in the child’s records.

Once the child has been pronounced dead, HM Coroner assumes responsibility for the body and must be informed.

The attending doctor will:

a)  ensure parents are kept fully informed of all proceedings, explaining future Police or Coroner involvement, including the Coroner’s authority to order a post-mortem examination.

b)  take a detailed and careful history of events leading up to and following discovery of the child’s collapse from the parents/carers. It is important that, as far as possible, the parents or carers account of the events should be documented verbatim. Where there is any concern about the circumstances surrounding the child's death then consideration should be given to speaking with the parents / carers separately so that their accounts can be compared and verified.

c)  obtain details of all other children and adults in the immediate family.  This activity will also include consulting with the Children’s Social Care Team to see if the child or other children in the household are subject to a Child Protection Plan.

d)  will speak to the ambulance crew who attended the scene for the purposes of information gathering.

e)  will speak to the member of staff initially allocated to provide support to the parents for the purposes of information gathering.

f)  take investigative samples as per UHL protocol.

Once points a to f have been completed, the Consultant in charge of the child or his deputy will consult with the SUDIC Dr on call in order to jointly review the presenting information and to consider the appropriate course of action.

18.13.6 Initial Multi-Agency Enquiries

In all unexpected deaths the child’s Consultant or attending doctor remains responsible to initiate multi-agency co-ordination. The Police, HM Coroner and the SUDIC Dr on call will be informed immediately together with the Children’s Social Care Team where relevant.

The SUDIC Dr on call will decide in conjunction with the DI on call and the attending doctor whether it will be helpful to undertake a joint health/police visit to the place where the child died within the next 24 hours. A joint visit should always be considered for infants and young children who die unexpectedly in a non-hospital setting.

If the death appeared to occur unexpectedly, but the child is known to have a life-limiting condition, the first step should be communication between the SUDIC Dr, palliative care team and DI to consider whether this death, although unexpected, is not unexplained.

If following liaison between the teams, the child's death remains unexpected and unexplained then a multi agency SUDIC response will be required, supported by the palliative care team and other agencies involved.

Following the joint visit the SUDIC Dr may decide to undertake a home visit with other key professionals as appropriate, to clarify information or ask additional questions. It will also offer the parents an early opportunity to ask questions and to be provided with relevant information as agreed.

The SUDIC Dr, working jointly with the CDR Manager, is responsible for co-ordinating the multi-agency response and should immediately oversee that the following agencies have been notified:

  • The Coroner
  • The Police
  • The LA children’s social care
  • The GP
  • The Health visitor/school nurse
  • Any other known involved professional

18.13.7 Joint Visit

The DI on call will discuss with the attending Clinician / SUDIC Dr and decide whether a joint visit is required. If a joint visit is required the DI will ring the Named Nurse on call and arrange for a planned visit to be undertaken during 9 – 5pm (including weekends and bank holidays).

If an urgent visit is required outside of these hours the Police may decide to undertake this visit by themselves or contact the SUDIC Dr on call to discuss their request in greater detail to resolve any concerns.

The attending DI and Named Nurse will obtain information relevant to the child’s death. The Named Nurses will be responsible for explaining to the parents the CDOP procedure, building on and supporting any information already offered to the parents including providing a copy of the Leaflet for Parents. If not already given by the A&E.

a)  The Named Nurse will be responsible for obtaining informed written consent to access family records in respect of siblings or parents as identified from the relevant agencies involved with the family.

b)  Where informed consent is not able to be obtained the Named Nurse should try to resolve any issues identified i.e. the use of interpreters, identifying an advocate for the family or inform the SUDIC Dr and CDR Manager of the circumstances and reasons for consent not being obtained.

c)  If informed consent is not obtained to access family records then information on the child may still be obtained using the DCSF Form A and Form Bs completed by the agencies involved and collated by the CDR Manager and forwarded to the CDOP Panel for discussion.

d)  The Named Nurses will provide appropriate information and support to relatives, carers and friends affected by the death and undertake an assessment of needs including recommendations in relation to ongoing support and feedback to the case discussion meeting (Phase 2).

e)  The CDR Manager will take responsibility to ensure the needs of the family are considered throughout the process and ensure support is offered to the family as required. If an appointment with the CDOP Chair is requested, the CDR Manager will facilitate this, to try to resolve any concerns or anxieties they may have.

18.13.8 Notification & Documentation Process following the unexpected death of a child

Any agency or professional who becomes aware of a child’s death during 9am- 5pm Monday to Friday should notify the SUDIC Dr and CDR Manager immediately, in order to initiate the SUDIC Response Process. They will then be requested to complete DCSF CDOP Form A Notification of Child Death and forward to the CDR Manager within 1-2 working days by fax. For any death that occurs outside of these hours the SUDIC Dr and Detective Inspector are to be contacted as soon as practicable. The CDR Manager is to be informed the next working day.

Where the death relates to a child 28 days and under and it is not clear whether the death was expected or unexpected, discussion will take place with the NNU medical staff, SUDIC Dr and DI.

HM Coroner officer has a key role in ensuring that the CDR Manager is informed of relevant unexpected child deaths under Rule 57A within 72 hours. In addition the CDOP office will inform HM Coroner of relevant deaths notified to the CDR Manager.

The CDR Manager may then request additional information from relevant agencies. All contact will be via the SPOC or agreed contact (e.g. where information is requested from a GP) to be compiled on CDOP Form B and subsections B2-10 as required. A request for information will be sent within 1-2 working days of notification of child’s death.

CDOP Form Bs are to be returned completed with as much information as possible within 10 working days. At the discretion of the CDR Manager CDOP Form Bs may be returned to agencies with a request for additional information.

If agencies do not return the documentation within the requested timescales, the CDR Manager will take further action.

18.13.9 Phase 2: within 5-7 days

The CDR Manager in conjunction with the SUDIC Dr will arrange a case discussion meeting to take place within 5-7days. If available the preliminary post mortem results will be discussed at this stage. Prior to the meeting, the CDR Manager will forward an agenda and a case summary to those requested to attend. The case discussion may involve:

  • The DI on call
  • Named Nurse undertaking the joint visit
  • All relevant health professionals, i.e. GP, HV, Midwife
  • Children’s social care, where relevant
  • Professionals from relevant other agencies i.e. school

In all cases of unexpected death the SUDIC Dr may also, at this stage, make appropriate arrangements for the family to be seen again. The SUDIC Dr will visit either the family home or identify another health professional to undertake this visit on their behalf. The Senior Detective may also wish to attend this subsequent meeting to inform the family about Police and Coronial procedures.

Following the meeting, the CDR Manager will collate actions identified and will ensure dissemination as appropriate. The CDR Manager may also request additional information from agencies to assist in further case discussions. In all cases, any inter-agency discussions should include establishing a clear plan for support to the bereaved family. A member of staff will be identified to offer ongoing support to the family as detailed in any action plan. It will be the responsibility of the CDR Manager to monitor that the action plan recommendations are met.

18.13.10 Phase 3: within 20-26 weeks

In all cases the CDR Manager will co-ordinate a further multi-agency meeting chaired by the SUDIC Dr involving relevant professionals following the final results of the post-mortem examination becoming known and collation of agency information about the child and family. Prior to the meeting, the CDR Manager will forward an agenda and a case summary of actions and outcomes to date to those requested to attend.

Those requested to attend may involve those who knew the family and child, and those involved in investigating the death e.g.:

The DI on call

  • Named Nurse who undertook the joint visit
  • All relevant health professionals, i.e. GP, HV, Midwife
  • Children’s social care, where relevant
  • Professionals from relevant other agencies i.e. school

The purpose of the meeting is to:

a)  Share information concerning the circumstances of the death, the child’s history, family history and subsequent investigations and identify the cause of death and/or those factors that may have contributed to the death.

b)  Plan future care for the family, including how the parents/carers will be informed of the outcome of the meeting and how they will be provided with ongoing support.

c)  Complete DCSF Analysis Proforma C and forward a copy to the CDOP Panel and HM Coroner.

Potential lessons to be learned may be identified at this stage. The outcome of the meeting may inform the inquest, if there is one. The possibility of abuse or neglect as cause or contributory factor in the death should be explicitly addressed where relevant and the outcome recorded.

In certain circumstances Phase 3 may be delayed or undertaken within another process. These circumstances include for example:

  • Criminal Investigations
  • HM Coroner’s Inquest
  • Serious Case Reviews
  • Child Protection Procedures
  • Legal Proceedings
  • Health & Safety Executive
  • MAPPA

In these instances a summary report will be submitted by the Agency to the CDR Manager.

Following the meeting, the CDR Manager will collate actions identified and will ensure dissemination as appropriate.

18.13.11 Ongoing Care of the bereaved family

The death of a child will be a traumatic loss for a family. Bereaved family members, parents and children, may require support to assist them in the bereavement process.  All agencies dealing with the family should have the relevant skills and training in order to aid this process.

Ensuring at every phase that the needs of the bereaved family are considered can be assisted by:

a)  Providing information in written form and ensuring appropriate ongoing information is shared by the identified professional as agreed at each phase of the process.

b)  Agreeing at each phase, which agency and lead professional will be responsible for supporting the family, including what information can or cannot be shared following consultation with the Police / HM Coroner. There will be an agreed format to ensure congruent information sharing.

c)  Providing opportunities to ask questions at different stages in the process are made available. Support to the family should be part of the SUDIC response process, and any actions or assessment of needs including recommendations are shared in writing to ensure they are incorporated within any inter-agency planning coordinated by the CDR Manager, SUDIC Dr & Named Nurses.

18.13.12 Post Mortems

All cases of unexpected death should be reported to HM Coroner and the decision may be taken to request a post mortem. In respect of sudden unexpected death in infancy it should be carried out by a paediatric pathologist within 48 hours of the child’s death, or as soon as reasonably practical thereafter. If there is anything to suggest that the circumstances of the death are suspicious or of an unnatural cause, the post mortem examination should also involve a Home Office Forensic Pathologist.

Prior to the post mortem examination, the pathologist should be fully briefed on the details of the child’s recent and past medical history and physical findings at presentation and interventions undertaken by the consultant paediatrician involved, via the HM Coroner’s Officer. This should include the findings of the joint visit by the Named Nurse and Detective Inspector on call via the SUDIC Dr. This includes viewing any photographs and videos of the death scene or child.

The pathologists should discuss the preliminary results of the post mortem examination with the Coroner. HM Coroner will then liaise with the CDR Manager. This information will be shared at the case discussion meeting Phase 2.

Appendix 1 - LLR SUDIC Flowcharts (PDF, 70kb)

Appendix 2 - For DCSF templates please visit: http://www.dcsf.gov.uk/everychildmatters/resources-and-practice/TP00045/

Appendix 3 - A leaflet for Parents and Families (PDF, 190kb)

Appendix 4 - Consent Form (PDF, 105kb)

Appendix 5 - Terms of Reference for a Child Death Overview Panel (PDF, 100kb)

Appendix 6 - Threshold Criteria (PDF, 125kb)

Appendix 7 - Child Death Overview Panel Contact Details including Deputy Single Point of Contact (SPOC's) (PDF, 33kb)

Appendix 8 - Information Sharing Agreement for the Leicester, Leicestershire and Rutland Local Safeguarding Children Board Child Death Overview Panel (PDF, 565kb)

Appendix 9 - Confidentiality Agreement (PDF, 25kb)

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