Child Death Review Procedures

The child death review process covers children: a child is defined in the Act as a person under 18 years of age, regardless of the cause of death.

Nottinghamshire and Nottingham City will have a combined Child Death Overview Panel (CDOP) which will provide the structural framework to review child deaths.

The geographical and population 'footprint' of child death review partners has been locally agreed and covers a child population such that CDOP will typically review at least 60 child deaths per year. It also takes into account networks of NHS care, and agency and organisational boundaries in order to reflect the integrated care and social networks of the area.

'The Partners' have established designated doctors for child deaths for Nottingham City, Nottinghamshire and Bassetlaw who are senior paediatricians who have a lead role in the review process. The designated doctors are spread across the 3 acute hospital trusts of Nottingham University Hospitals NHS Trust, Sherwood Forest Hospitals NHS Foundation Trust and Doncaster and Bassetlaw Hospitals NHS Foundation Trust and are supported by Lead Nurse roles.

The appropriate designated doctor for child deaths is notified of each child death within their hospital trust and is sent relevant information.

The partners may request a person or organisation to provide information to enable or assist the reviewing and/or analysing of a child's death. The person or organisation to whom a request is made must comply with such a request and if they do not do so, the partners may instigate legal action to enforce.

The partners may choose to review the death of a child in their local area even if that child is not normally resident there. Potential 'out of area cases' will be brought to the attention of the designated doctor for child deaths and the CDOP Chair who will decide whether it is useful for CDOP to review an out of area case. In particular, the partners will consider this for the deaths of looked-after children.

The partners have publicised information on the arrangements for child death reviews on the Nottinghamshire Safeguarding Children Partnership, the Nottingham City Safeguarding Children Partnership and the relevant Integrated Care Boards websites

All local organisations or individual practitioners that have had involvement in the case should co-operate, as appropriate, in the child death review process and should also have regard to any guidance on child death reviews issued by the government.

Organisations have a responsibility to share relevant information with the child death review partners. Reporting forms (Form B) should be completed by the relevant responsible officer for the organisation and shared with CDOP.

There is a specific requirement on registrars of births and deaths to supply child death review partners with the particulars of the death entered in the register in relation to any person who was or may have been under the age of 18 at the time of death. A similar requirement exists where the registrar corrects an entry in the register.

The registrar must also notify child death review partners if they issue a Certificate of No Liability to Register (where a death is not required by law to be registered in England or Wales) where it appears that the deceased was or may have been under the age of 18 at the time of death.

The information must be provided to the appropriate child death review partners (which cover the sub-district in which the register is kept) no later than seven days from either the date the death was registered, the date the correction was made or the date the certificate was issued.

The Nottinghamshire Coroner has a duty to notify the child death review partners for the area in which the child died or where the child's body was found within three working days of deciding to investigate a death or commission a post-mortem.

The Nottinghamshire Coroner has a duty to share information with the relevant child death review partners.

The organisation where the child's death is declared (usually the acute hospital) is responsible for carrying out a child death review meeting (see below).

The child death review process covers children; a child is defined in the Children Act 1989 as a person under 18 years of age. A child death review must be carried out for all children regardless of the cause of death.

This includes the death of any live-born baby where a death certificate has been issued. In the event that the birth is not attended by a healthcare professional, child death review partners may carry out initial enquiries to determine whether or not the baby was born alive. If these enquiries determine that the baby was born alive the death must be reviewed.

For the avoidance of doubt, it does not include stillbirths, late foetal loss, or terminations of pregnancy (of any gestation) carried out within the law.

• Stillbirth: baby born without signs of life after 24 weeks gestation;
• Late foetal loss: where a pregnancy ends before 24 weeks gestation.

Cases where there is a live birth after a planned termination of pregnancy carried out within the law are not subject to a child death review.

A number of notifications must be made when a child dies and these are carried out by the hospital based child death review teams via a cascade process to the child's GP and other professionals, the Child Health Information System, the CDOP administrator, and, (once operational) the National Child Mortality Database. A referral to the Coroner is required for all child deaths in Nottinghamshire and Nottingham City.

A number of decisions also need to be made by professionals in the hours immediately following the death of a child. These include:

• How best to support the family (see key worker below);
• Whether the death meets the criteria for a Joint Agency Response;
• What format the child death review meeting should take;
• Whether the death meets the criteria for a health serious incident investigation.

Whenever a child dies, practitioners should work together in responding to that death in a thorough, sensitive and supportive manner. The aims of this response are to:

• Establish, as far as is possible, the cause of the child's death;
• Identify any modifiable contributory factors;
• Provide ongoing support to the family;
• Learn lessons in order to reduce the risk of future child deaths and promote the health, safety and wellbeing of other children;
• Ensure that all statutory obligations are met.

A 'key Worker' should be identified for ongoing support throughout the time of the child death review process (this may or may not be the same person who is allocated to support the family at the initial presentation at hospital). A 'Key Worker' is defined as "a person who acts as a single point of contact for the bereaved family, who they can turn to for information on the child death review process, and who can signpost them to sources of support. This person will usually be a healthcare professional". Core competencies for the key worker can be found at Appendix 5 of Child Death Review Statutory and Operational Guidance (England).

The key worker should provide the family with a paper copy of the leaflet: When a Child Dies - a Guide for Parents and Carers.

When dealing with bereaved families health professionals should have due regard to chapter 2 of the NHS England publication National Guidance on Learning from Deaths

If the death does not meet the criteria for a joint Agency Response as outlined below, information will be gathered in preparation for a child death case review meeting. At the meeting, all matters relating to an individual child's death are discussed by professionals involved with the case. The child death review meeting should be attended by professionals who were directly involved in the care of that child during his or her life and in the investigation into his or her death, and should not be limited to medical staff.

Joint Agency Response to Child Deaths

A Joint Agency Response is required if a child's death:

• Is or could be due to external causes;
• Is sudden and there is no immediately apparent cause (including sudden unexpected death in infancy/childhood);
• Occurs in custody, or where the child was detained under the Mental Health Act;
• Occurs where the initial circumstances raise any suspicions that the death may not have been natural (this could include a child death in a hospital setting;
• Occurs in the case of a stillbirth where no healthcare professional was in attendance.

The on-call Lead Health Professional for Child Deaths should be consulted to ensure that there is a joint discussion and decision between lead professionals for health, police and social care about next steps as per the process set out in Sudden unexpected death in infancy and childhood Multi-agency guidelines for care and investigation (November 2016). In the case of a stillbirth an obstetrician should be consulted.

If a baby dies within 24 hours of birth or shortly thereafter due to an event related to the birth whilst under medical supervision, and there is a clear medical explanation for the death, this should not require a joint agency response.

The purpose of a joint agency response to the death of a child is to:

• Understand the reasons for the child's death;
• Address the possible needs of other children in the household and of all family members;
• Identify those deaths that may be as a result of abuse or neglect and ensure an appropriate response;
• Consider any lessons to be learnt about how best to safeguard and promote the welfare of children in the future including consideration of any wider public health implications.

The revised procedure sets out a structure within which reasoned judgements can be made when evaluating a child death on the basis of all available information. It is important therefore that all staff remain open minded when considering any death and avoid reaching conclusions inappropriately outside of the agreed processes.

To support this function the joint agency response is provided by the Designated Doctor for Child Deaths (who will be an experienced consultant paediatrician) supported by a number of on call Child Death Paediatricians and Child Death Nurses, in conjunction with representatives from the Police and Children's Social Care.

Where Children's Social Care and the Police are referred to, unless otherwise specified, this means Children's Social Care and the Police covering the area in which the event leading to the child's death occurred.

In principle it is recognised that all information relevant to the enquiry should be shared by all agencies. The Police, however, may consider certain information sub judice or subject to continuing investigation and this may preclude it being released in an open forum, especially where the parents may be present. In these cases they should ensure that the information is shared with colleagues in other agencies in an appropriate and timely manner. Any decision not to share information should be recorded by the Senior Investigating Officer (SIO) in their Police log.

The flowchart below sets out the sequence of events that should unfold in a joint agency response. Please note the sequence and timing of events may fluctuate depending on the individual circumstances presented by the child's death.

Where a child dies suddenly in the community the child should in almost all circumstances be taken to a Hospital Emergency Department. However, the timing of this will depend upon the circumstances of the child's death.

Wherever there are immediate concerns as to the circumstances of the child's death the Police retain primacy for the crime scene and will need to carry out a forensic examination. The Police will discuss with the Coroner and Home Office Pathologist arrangements for examination and removal of the body.

Where the child has been pronounced dead at the scene or is 'obviously dead' then there may be a delay in the removal of the body to the Emergency Department pending forensic examination. In these circumstances a protocol has been agreed with the East Midlands Ambulance Service (EMAS) that an ambulance will return to the scene to transport the child's body to the Emergency Department at the authorisation of the police.

Very occasionally it may not be seen as appropriate to remove the child's body to the Hospital Emergency Department (e.g. where the body is in an advanced stage of decomposition). In such circumstances the appropriate course of action should be agreed between the SIO from the police and the on call Lead Health Professional.

Once the child has been pronounced dead in Hospital (or the death has been confirmed) the responsible Consultant Paediatrician will inform the parents of the death and explain the process of the joint agency response to child deaths. Form 1, 'Emergency Department' (joint agency response child deaths), should be completed in the Emergency Department (ED) by a member of the ED Team. It is the responsibility of the hospital consultant to share this information with the on call Lead Health Professional and ensure all other relevant professionals have been informed of the death. This will include the Coroner, the local Divisional Police and Children's Social Care covering the area where the event leading to death occurred. For young people of 16 and 17 years old this may be a Consultant responsible for the child's care other than a Paediatrician. A member of the Hospital staff should be allocated to the family for ongoing support whilst at hospital.

A 'key Worker' should be identified for ongoing support throughout the time of the child death review process (this may or may not be the same person who is allocated to support the family at the initial presentation at hospital).

The key worker should provide the family with a paper copy of the leaflet: When a Child Dies - a Guide for Parents and Carers.

Where the death occurs outside of usual office hours the Emergency Duty Team (EDT) of the appropriate Children's Social Care department needs to be contacted by the responsible Consultant Paediatrician. The EDT is responsible for checking whether the child and family are known to them and engaging in initial discussions with key staff and handover to the day time teams.

Having been made aware of the child's death, the on call Lead Health Professional will check that all relevant professionals have been informed of the death (as above), and will share information with the wider group e.g. the 0-19 Healthy Family Teams, midwife, Designated Nurse for safeguarding children, G.P. and other specialist health workers involved in the child's care. Planning discussions will take place between staff at an operational level in the lead agencies i.e. Health, Police (SIO) and Children's Social Care (team manager) to decide what should happen next and who will do what. The Coroner and other relevant persons or agencies, including the Fire Investigation Team if the death has been caused by fire, must also be contacted. The agreed outcome of these discussions will be recorded by the on call Lead Health Professional on Form 3, 'Record of Interagency Discussion' (joint agency response child deaths).

On receipt of this information the Children's Social Care team manager should immediately inform their Service Manager or the on call senior manager if out of hours, who in turn will inform the respective Head of Service for Fieldwork and Head of Service for Safeguarding and Independent Review/Quality Assurance.

The Police SIO and the on call Lead Health Professional should make a decision about whether a joint visit should be made to the place where the child has collapsed and/or died. See chapter 5. Assessment of the environment and circumstances of the death Sudden unexpected death in infancy and childhood Multi-agency guidelines for care and investigation (November 2016).

This should almost always take place for children under 2 years who die suddenly with no medical explanation but should be considered in all cases. Where agreed, this visit should take place within 24 hours after the child's death and in most circumstances be a joint visit between the Police and the Lead Health Professional (where the child is an open case to Children's Social Care a Social Worker may also attend). Information from this visit will be recorded by the Lead Health Professional on Form 2 the 'Record of Home Visit' (child deaths).

After this visit the Lead Health Professional will facilitate a discussion with the Police (SIO), Children's Social Care representative (team manager) along with other relevant professionals to review any information obtained from the visit that could raise concerns about the possibility of abuse or neglect contributing to the child's death. This can take the form of a telephone discussion or meeting dependent on the circumstances of the case. If such concerns arise, then the case should be investigated as laid out in the Core Safeguarding Procedures section of these procedures. The outcome of these discussions will be recorded by the Lead Health Professional on the Form 3, 'Record of Interagency Discussion' (child deaths).

In all cases the police will complete an Initial Coroner's Report within 24 hours. The lead Health Professional will supply the Coroner with copies of Forms 1 and 2 (ED and Home Visit Forms), at the earliest opportunity and within a maximum of 24 hours.

The level and type of communication following the death of a child which requires a joint agency response will depend on the circumstances of each case. In the majority of cases this will include an Initial Case Discussion Meeting convened by the lead heath professional who will be responsible for ensuring that representatives from relevant agencies are invited to attend. This should be held within 3 working days where possible. The meeting will follow the agenda set out in the Initial Case Discussion Meeting Agenda and will be minuted by the Health Child Death Review Team administrator. Minutes from this meeting will be sent to the Coroner.

Where the child who has died, or a child in the same household is an open case to Children's Social Care (i.e. the child is on a Child Protection Plan or Child in Need Plan), or if there is a police led investigation into suspicions of deliberate harm, or if there is agreement that there are concerns regarding the possibility of abuse or neglect contributing to the child's death, the function of the Initial Case Discussion Meeting will be carried out within a Strategy Meeting (see Strategy Meeting below). This will be chaired by the Child Protection Coordinator (CPC) in the County and by the Principal Manager or / Independent Reviewing Officer (IRO) for the city. Professional judgement will need to be used when deciding the most appropriate agency to lead the Initial Case Discussion Meeting. If a child is open to Children's Social Care for support reasons e.g. Community Disability Teams providing Occupational Therapy support, then it may be appropriate for such cases to be health led.

The Strategy Meeting should take place within 48hrs where practically possible. This does not prevent strategy discussions taking place between the parties in the interim, especially where there is a need to consider the immediate safety of siblings; the on call health professional should be invited. The CPC/IRO will also be responsible for co-ordinating the Child Death Review Meeting when all enquiries are complete.

Children's Social Care should make enquiries such that relevant background information in relation to the child that has died and any siblings is obtained from all Children's Services with the Local Authority e.g. Youth Offending Team, Education, Youth Service and Children's Centres.

The Police have a responsibility to investigate unexplained deaths of children on behalf of the Coroner. The role of the on call Lead Health Professional at this stage is to ensure all activity between agencies is coordinated.

Children with recognised life limiting conditions are usually cared for by a multi-agency team led by a Paediatrician. Some of these will have a documented Personal Resuscitation Plan (PRP) which will have been shared with all agencies involved. The death of these children may not be anticipated. However, many children who are at risk of rapid deterioration or sudden death do not have a formal PRP in place even though their death may be anticipated. The Lead Health Professional will work closely with the responsible Consultant to manage the response to the child's death.

Where there are immediate concerns that abuse or neglect has been a factor in the child's death, the case will be subject of a joint investigation involving the Police and Children's Social Care from the outset. In these circumstances Children's Social Care have the responsibility for coordinating the overall safeguarding investigation as laid out in the inter-agency Core Safeguarding Procedures and the police have responsibility for coordinating any criminal investigation. The function of the Initial Case Discussion Meeting will be incorporated into these processes.

At any stage throughout this process, where concerns emerge that abuse or neglect have been a factor in the child's death, joint investigations will be undertaken. The Police will take the lead in the criminal investigation and Children's Social Care will take the lead for coordinating inter-agency activity, and information sharing. Input from Health colleagues will be coordinated by the on call Lead Health Professional. The on call Lead Health Professional should be seen as central to discussions and be invited to any meetings convened.

Children's Social Care should initiate S47 Enquiries following the strategy discussion and the procedures outlined in Core Safeguarding Procedures followed. A joint agency review Strategy Meeting will be convened within 48 hours of the decision being made. The Strategy Meeting will be chaired by the CPC/IRO and consideration given to the convening of an Initial Child Protection Conference.

The circumstances of these cases may meet the criteria for a Local or National Child Safeguarding Practice Review as outlined in Child Safeguarding Practice Reviews and the procedure in that section should also be followed.

The agenda for the Strategy Meeting is outlined in Child Protection Enquiries Procedure, Strategy Discussion/ Meeting and the following specific considerations should be included:

• Establish whether any concerns are indicated by any initial views about the cause of death;
• Establish whether there is any relevant background information to indicate the need for further enquiries;
• Agree what further enquiries will be undertaken and by whom;
• Consider whether S47 Enquiries should be continued;
• Agree how and when parents should be notified of the enquiries;
• Focus on any surviving or unborn siblings as well as the child who has died;
• Use of the Initial Case Discussion agenda, invites and information sheet for attendees.

The SIO from the Police should ensure that the Coroner's Office is informed of the outcome of the Strategy Meeting and any subsequent Strategy Meetings which are held. Upon receipt of the final post mortem results it will be the responsibility of the CPC/IRO to coordinate a final Joint Agency Response Child Death Review Meeting whether or not this meeting falls outside of the Child Protection Procedures. Additionally, the final post mortem results and ongoing investigation may provide further information indicating the need for a further joint agency response Strategy Meeting.

The deaths of children in certain specific situations are covered in detail in the Child Death Review Statutory and Operational Guidance (England). This guidance should be referred to in the following cases:

• Deaths overseas of children normally resident in England;
• Deaths of children with learning disabilities and links to the Learning Disabilities Mortality Review (LeDeR) Programme;
• Deaths of children in adult healthcare settings e.g. adult intensive care units (ICUs);
• Deaths by suicide;
• Deaths within an Inpatient Mental Health setting;
• Deaths in custody.

In almost all cases of an unexplained or traumatic child death the Coroner will order a post mortem examination to be carried out. The on call Lead Health Professional should share the information collated thus far and pass copies of Forms 1,2 (ED and Home Visit Forms) and other relevant information to the Coroner. A copy of Form 1 is to remain with the body. Where a Home Office Pathologist is to conduct the post mortem this information will be passed via the Police SIO or coroner's officer.

The preliminary results of the post mortem examination (in most circumstances) should be discussed by the Pathologist and the Police SIO as soon as possible. The Coroner should be informed immediately of the initial results. This will be the responsibility of the Pathologist.

The Police should share relevant information from the post mortem with the lead professionals from Health and Children's Social Care and where appropriate arrange for a further joint agency response meeting to be convened.

The Coroner should be informed of any relevant new information coming to light as a result of these considerations. This will be the responsibility of the Police SIO.

There are situations that are not clear-cut and might need consultation with the designated paediatrician and others in the joint agency team, such as the example of an infant who is successfully resuscitated from an out-of-hospital arrest but dies subsequently or who may survive for a period of time.

In this situation, the infant might live for days or weeks before dying, usually through withdrawal of care following discussions with the family. As the out-of-hospital arrest was sudden and unexpected, and the prognosis was poor, the police may secure the scene but will not be able to do this indefinitely. Thus, such a presentation should be discussed with the designated paediatrician in order for a home visit to be undertaken, despite the infant remaining alive, as important information might be found that can assist the treating team and police. Which professionals should undertake the home visit needs to be assessed on a case by case basis following a discussion between the Lead Health Professional, Police and Children's Social Care. Further guidance in this area can be found in the section on unusual clinical situations Sudden unexpected death in infancy and childhood Multi-agency guidelines for care and investigation (November 2016).

The child death review meeting (CDRM) is the final multi-professional meeting where all matters relating to an individual child's death are discussed by the professionals directly involved in the care of that child during life and their investigation after death. This takes place prior to the review at the CDOP.

The nature of this meeting will vary according to the circumstances of the child's death and the practitioners involved. For example, it could take the form of a final case discussion following a Joint Agency Response; a perinatal mortality review group meeting in the case of a baby who dies in a neonatal unit; a hospital-based mortality meeting following the death of a child in a paediatric intensive care unit; or similar case discussion.

The review meeting should be flexible and proportionate, and focused on local learning. It is important that all deaths are reviewed. However, in certain circumstances it may be appropriate for the review to be quite brief or for the meeting to discuss one child or several children. In every case, the Analysis Form should be drafted at the CDRM and then sent to the relevant CDOP.

In all cases, the aims of the child death review meeting are:

• To review the background history, treatment, and outcomes of investigations, to determine, as far as is possible, the likely cause of death;
• To ascertain contributory and modifiable factors across domains specific to the child, the social and physical environment, and service delivery;
• To describe any learning arising from the death and, where appropriate, to identify any actions that should be taken by any of the organisations involved to improve the safety or welfare of children or the child death review process;
• To review the support provided to the family and to ensure that the family are provided with:
  • The outcomes of any investigation into their child's death;
  • A plain English explanation of why their child died (accepting that sometimes this is not possible even after investigations have been undertaken) and any learning from the review meeting.
• To ensure that CDOP and, where appropriate, the coroner is informed of the outcomes of any investigation into the child's death; and
• To review the support provided to staff involved in the care of the child.

It is the responsibility of the organisation where the child's death is declared to arrange the child death review meeting. Where a Joint Agency Response has occurred the lead health professional (or CPC / Principal Manager / IRO* where a Strategy Meeting has been held in place of an Initial Case Discussion) would be responsible for arranging this meeting.

The Child Death Review Meeting should be chaired by a lead health professional for the child death review process within the organisation where death was declared, or the lead health professional in a joint agency response. If the lead professional also had overall clinical responsibility for the child, the role of chair should be delegated to another colleague to avoid any perceived conflict of interest.

In those cases where a Strategy Meeting was held in place of an Initial Case Discussion, if it has been agreed that there are no ongoing concerns for any children in the family, the final case discussion meeting can be chaired by health. This agreement should be reached between the Lead Health Professional and the manager of the case within social care in liaison with the CPC/IRO who chaired the initial meeting. The meeting should include the final post mortem results and the outcome of any police investigation.

The following professionals should be invited:

• Hospital or community healthcare staff involved with the child at the end of his/her life, and those known to the family prior to this event;
• Pathologist, if a hospital post-mortem examination has taken place;
• Other professional peers from relevant hospital departments and community services to ensure objective review of treatment decisions;
• Patient safety team if a serious incident investigation has taken place;
• Senior investigating police officer, if there is a Joint Agency Response; or
• other practitioners for example social work, ambulance and fire services, primary care clinicians, school nurse, head teacher, representatives from voluntary organisations.

The Child Death Review Meeting should be chaired by a lead health professional within the organisation where death was declared, or the lead health professional in a Joint Agency Response.

The meeting should take place as soon as is practically possible, ideally within three months, although serious incident investigations and the length of time it takes to receive the final post-mortem report will often cause delay. In order to best capture the views of those directly involved, it may be beneficial to start the process as soon as possible, prior to the formal CDRM. The CDRM should occur before any coroner's inquest, and before the CDOP meets. Further guidance in relation to the timing of the Child Death Review Meetings can be found in chapter 4 of Child Death Review Statutory and Operational Guidance (England).

The CDRM is a meeting for professionals, however, parents should be informed of the meeting by their key worker and have an opportunity to contribute information and questions through their key worker or another professional.

At the meeting's conclusion, there should be a clear description of what follow-up meetings have already occurred with the parents, and who is responsible for reporting the meeting's conclusions to the family.

The meeting should consider the following standard agenda items:

• Case presentation;
• Findings from the post-mortem examination (or from the Joint Agency Response or serious incident investigation);
• Questions raised by the family;
• Issues reflecting discussion;
• Lessons learnt and agreed actions;
• Conclusions regarding contributory and modifiable factors;
• Family follow up;
• Staff support.

The meeting should consider the domains contained in form C and a draft form C should be completed and provided to the Child Death Overview Panel (CDOP).