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Introduction
7.1 The majority of child deaths occur as a result of natural causes and are an unavoidable tragedy for the family.
7.2 About 1, in 2,000 children will die unexpectedly in infancy. In the absence of a familial disorder, the incidence of unexpected death decreases and two such deaths occurring in the same family is extremely unusual and should arouse suspicion. The incidences of such deaths in children decrease as the child gets older. Professional staff from a number of different agencies will become involved throughout the process of establishing the cause of death.
7.3 Working Together to Safeguard Children 2010 provides statutory guidance and procedures to be followed when a child dies in the Local Safeguarding Children Board (LSCB) area covered by a Child Death Overview Panel. There are two interrelated processes for reviewing child deaths (either which can trigger a Serious Case Review (SCR):
- rapid response by a group of key professionals who come together for the purpose of enquiring into and evaluating each unexpected death of a child and
- an overview of all child deaths up to the age of 18 years (excluding both those babies who are stillborn and planned terminations of pregnancy carried out within the law in the LSCB area, undertaken by a panel.
7.4 CDOP is responsible for reviewing the available information on all child deaths and is accountable to the LSCB Chair. The disclosure of information about a deceased child is to enable the LSCB to carry out its statutory functions relating to child deaths.
7.5 The Local Case Discussions and the CDOP examine the circumstances surrounding a child’s death and make recommendations where appropriate. The LSCB use the findings from all child deaths, to identify patterns or themes and inform local strategic planning on how best to safeguard and promote the welfare of the children in their area.
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Rapid Response
7.4 Each death of a child is a tragedy for his or her family (including any siblings), and subsequent enquiries/investigations should keep an appropriate balance between forensic and medical requirements and the family’s need for support.
7.5 A minority of unexpected deaths are the consequence of abuse or neglect, or are found to have abuse or neglect as an associated factor. In all cases, enquiries should seek to understand the reasons for the child’s death, address the possible needs of other children in the household, the needs of all family members and, also consider any lessons to be learnt about how best to safeguard and promote children’s welfare in the future.
7.6 Families should be treated with sensitivity, discretion and respect at all times, and professionals should approach their enquiries with an open mind.
7.7 It is acknowledged that each death has unique circumstances and the professionals involved will have their own experience and expertise gained from handling previous cases. Nevertheless, there will be some common aspects to the management of those child deaths where the cause of death is unknown. It is important to share good practice and achieve a consistent approach.
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Role of Rapid Response
7.8 An information sharing meeting may be convened. If there are any concerns about a possible unnatural death, or that abuse or neglect were factors then a strategy meeting will be convened under child protection procedures.
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Unexpected Child Death
The Definition of an Unexpected Child Death
7.9 An unexpected death is defined as the death of an infant or child (less than 18 years old) which:
- was not anticipated as a significant possibility for example, 24 hours before the death; or
- where there was a similarly unexpected collapse or incident leading to or precipitating the events which led to the death
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Roles and Responsibilities When Responding Rapidly to an Unexpected Death of a Child
7.10 This guideline should apply to children and young people up to the age of 18 years.
7.11 When dealing with an unexplained child death, all agencies need to follow five common principles:
- Sensitivity and open minded balanced approach
- An inter-agency response
- Sharing of information
- Appropriate response to the circumstances
- Preservation of evidence
7.12 The professionals who come together as a team will be carrying out their normal functions, i.e. as a paediatrician, GP, nurse, health visitor, midwife, mental health professional, substance misuse worker, social worker, Youth Offending Team worker, probation or police officer in response to the unexpected death of a child in accordance with this guidance. They should also work according to a protocol agreed with the local coronial service. Other professionals known to the family from specialist agencies should be accessed on a case by case basis to support the core team, i.e. hospice support workers, children’s community nurses.
7.13 The joint responsibilities of these professionals will include:
- responding quickly to the unexpected death of a child;
- making immediate enquiries into and evaluating the reasons for and circumstances of the death, in agreement with the coroner;
- undertaking the types of enquiries/investigations that relate to the current responsibilities of their respective organisations when a child dies unexpectedly. This includes liaising with those who have ongoing responsibilities for other family members;
- collecting information in a standard, nationally agreed manner;
- providing support to the bereaved family and where appropriate referring on to specialist bereavement services; and
- following the death through and maintaining contact at regular intervals with family members and other professionals who have ongoing responsibilities for other family members to ensure they are informed and kept up to date with information about the child’s death.
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Duty of Registrar
7.14 Registrars must notify the appropriate LSCB about the deaths of children under the age of 18, within seven days from the date the death was registered.
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Duty of Coroner
7.15 The Coroner has a duty to inform the LSCB for the area in which the child died of the fact of an inquest or post mortem. Coroners are also given the powers to share other information with the LSCB for the purposes of reviewing child deaths and carrying out Serious Case Reviews.
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Duty of all Agencies Involved with the Child
7.16 All agencies involved with the child prior to his or her death are required to complete an agency report form outlining their involvement and giving details of the child’s circumstances. They are required to communicate effectively with other agencies to keep them informed of circumstances and their involvement with the child. Any professional (or member of the public) hearing of a local child death in circumstances that mean it may not yet be known about (for example, a death occurring abroad) can inform the Chair of the LSCB.
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Role of Designated Officer
7.17 The Child Death Designated Officer is the person to whom child death notifications are sent. All LSCBs are required to have a designated officer for child deaths. The role of the CDOP co-ordinator is to ensure that all information is received within the correct timescales and that this is available for the CDOP to consider.
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Notification of the Child’s Death
7.18 Deaths should be notified by the professional confirming the fact of the child’s death. For unexpected deaths, this will be at the same time as they inform the Coroner and the Child Death Designated Officer (CDDO). If this is not the area in which the child is normally resident, the designated person should inform their opposite number in the area where the child normally resides.
7.19 In these situations, it should be decided on a case-by-case basis which Panel should take responsibility for gathering the necessary information for a Panel’s consideration. In some cases this may be done jointly.
7.20 Any person notify the Child Death Designated Officer of the death of a child should provide as much detail as is known to them in relation to the child and family and the circumstances of the death. They should inform the CDDO or the CDOP co-ordinator of any professionals known to be involved with the child or family by completing Form A.
7.21 Following notification of the death of a child, the CDOP Co-ordinator should seek to establish which agencies and professionals have been involved with the child or family either prior to or at the time of death. A lead professional should be nominated in each agency to assist with this.
7.22 The professionals involved will be required to complete Form B if the death was either an early or a late neonatal death, the standard CMACE (Centre for Maternal and Child Enquires) Perinatal Death Notification form should continue to be completed as normal and a copy should be sent to both the regional CMACE office and the relevant LSCB Child Death Overview Panel Co-ordinator.
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Professionals Responding to Information Requests
7.23 Professionals receiving an agency report form (Form B) should retrieve any relevant case records for the child or other family members to complete any information known to them or their organisation and return the form to the CDOP co-ordinator using a secure means of transfer. This should be completed at the earliest opportunity to allow the CDOP to review the child’s death in a timely manner. There will be circumstances where, because of ongoing medical or police investigations information may not be available. It may be appropriate for the lead professional in each agency to collate information from all involved professionals within their agency.
7.24 All professionals have a duty to provide the necessary information to the CDOP co-ordinator, to allow for a meaningful review. Agency reports should be completed and sent to the CDOP co-ordinator within three weeks. Any non-compliance with a request for completion of an agency report form will be followed up and ultimately a letter of non compliance will be sent to the relevant Chief Executive.
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Process for a Rapid Response and Local Review from Professionals to all Unexpected Deaths of Children (0-18 years)
7.25 The Designated Paediatrician responsible for unexpected deaths in childhood should be consulted where professionals are uncertain about whether the death is unexpected. If in doubt, the processes for unexpected child deaths should be followed until the available evidence enables a different decision to be made. When a child dies unexpectedly, several investigative processes may be instigated, particularly when abuse or neglect is a factor. This guidance intends that the relevant professionals and organisations work together in a coordinated way, in order to minimise duplication and ensure that the lessons learnt contribute to safeguarding and promoting the welfare of children in the future.
7.26 It is intended that those professionals involved (before and/or after the death) with a child who dies unexpectedly should come together to respond to the child’s death. The work of the team convened in response to each child’s death should be co-ordinated by the Designated Paediatrician responsible for unexpected deaths in childhood.
7.27 The professionals who come together as a team will carry out their normal functions – for example, as a Paediatrician, GP, Nurse, Health Visitor, Midwife, Mental Health professional, Substance Misuse worker, Social Worker, Youth Offending Team worker, Probation or Police Officer in response to the unexpected death of a child in accordance with this guidance. They should also work according to the protocol agreed with the local coronial service. Other professionals known to the family from local coronial service. Other professionals known to the family from specialist agencies will be accessed on a case by case basis to support the core team; i.e. hospice support workers, children’s community nurses.
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Responding Quickly to the Unexpected Death of a Child
7.28 The role of the Rapid Response Team is to:
- Make immediate enquiries into the evaluating the reasons for and circumstances of the death, in agreement with the coroner:
- Undertake the types of enquiries/investigations that relate to the current responsibilities of their respective organisations when a child dies unexpectedly. This includes liaising with those who have ongoing responsibilities for other family members;
- Collect information in a standard, nationally agreed manner;
- Providing support to the bereaved family, and where appropriate referring on to specialist bereavement services; and
- Follow the death through and maintaining contact at regular intervals with family members and other professionals who have ongoing responsibilities for other family members, to ensure they are informed and kept up-to-date with information about the child’s death.
7.29 If, during the enquiries, concerns are expressed in relation to the needs of surviving children in the family, discussions should take place with Safeguarding and Specialist Services. It may be decided that it is appropriate to initiate a initial assessment using the Framework for the Assessment of Children in Need and their Families (2000).
7.30 If concerns are raised at any stage about the possibility of surviving children in the household being abused or neglected, the LSCB procedures for safeguarding children Safeguarding Specialist Service has lead responsibility for safeguarding and promoting the welfare of children.
7.31 When a child dies unexpectedly and no doctor is able to issue a medical certificate of the cause of death, the child’s death must be reported to the Coroner. Agencies and professionals contributing to the process should co-operate with their local Coroner to ensure the Inquest is able to proceed appropriately. The process of the rapid response can greatly assist the Coroner in gathering information to inform the Inquest.
7.32 The type of response to each child’s unexpected death will depend to a certain extent on the age of the child, but there are some key elements that underpin all subsequent work. Supplementary information is required for making enquires into, for example deaths of infants, those deaths in hospital that are the result of trauma, and suicides.
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Other Related Processes
Criminal Investigations
7.33 The Police are the lead agency for any criminal investigation. The Police must be informed immediately that there is a suspicion of a crime, to ensure that the evidence is properly secured and that any further interviews with family members and other relevant people accord with the requirements of the Police and Criminal Evidence Act 1984.
7.34 Where there is an ongoing criminal investigation, the Senior Investigating Officer and the Crown Prosecution Service must be consulted as to what it is appropriate for the professionals involved in reviewing a child’s death to be doing, and what actions to take in order not to prejudice and criminal proceedings. Where a death of a young person occurs in custody, local agencies must co-operate with the Police and Probation Ombudsman.
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Youth Offending Teams
7.35 The Youth Justice Board for England and Wales (YJB) requires Youth Offending Teams (YOTs) to report and undertake Local Reviews of youth offending practice in cases where a child or young person has either died or attempted suicide whilst under supervision or within three months of the expiry of supervision. Where a child has died, the Local Management Review undertaken by the YOT in relation to the death should feed into the child death processes initiated by the CDOP.
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Serious Case Review
7.36 If it is thought, at any time, that the criteria for a Serious Case Review might apply, the chair of the LSCB should be contacted and the Serious Case Review should be followed. If a Serious Case Review is initiated, the CDOP will not be able to conclude the Child Death Review until after the Serious Case Review Executive Summary has been published. This should not however prevent lessons form being learnt and from being acted upon.
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Dealing with Families
7.37 Families should be treated with sensitivity, discretion and respect at all times and professionals should approach their enquires with an open mind.
7.38 Chronic illness, disability and life-limiting conditions account for a large proportion of child deaths.
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Rapid Response to a Child Death in a Non-Hospital Setting
7.39 The purpose of a joint home visit is to identify all possible factors that may assist to determine why a child has died. Parents should be offered the opportunity to be present at the home visit as they may remember further details of events leading up to the child’s death.
7.40 The information to be gathered at the interview and home visits is included in the history proforma completed by the Rapid Response Nurse.
7.41 The Rapid Response Nurse, is responsible for contacting Children’s Social Care, GP, Health Visitor, Midwife, School Nurse and any other relevant agencies to obtain background information about the child and family.
7.42 After discussion with the Police Senior Investigating Officer, Designated Paediatrician for Child Deaths and other agencies it may be appropriate to hold a Rapid Response meeting to facilitate information sharing. It is the role of the Rapid Response Nurse to convene this meeting.
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Child Death Overview Panel
7.43 The Requirement to establish a Child death review Process (CDRP) is contained in Chapter 7 of “Working Together to Safeguard Children” 2006. The requirement is statutory and comes into force on the 1st of April 2008. The North East Lincolnshire Child Death Overview Panel is in place as of this date.
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The Regulations relating to child deaths:
One of the LSCB functions, set out in the Regulation 6 of the Local Safeguarding Children Boards Regulations 2006, in relation to the deaths of any children normally resident in their area is as follows:
- Collecting and analysing information about each death with a view to identifying -
(i) any case giving rise to the need for a review mentioned in Regulation 5(1)(e);
(ii) any matters of concern affecting the safety and welfare of children in the area of the authority; and
(iii) any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area;
(iv) putting in place procedures for ensuring that there is a co-ordinated response by the authority, their Board partners and other relevant persons to an unexpected death.
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Reviewing Deaths of all Children
7.45 An overview of all child deaths in will be undertaken by the Child Death Overview Panel up to the age of 18 years in the LSCB area covered by the CDOP. This will be a paper based review, 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 including, perhaps the coroner.
7.46 The Panel:
- has a fixed core membership to review these cases, with flexibility to co-opt on other relevant professionals as and when appropriate;
- will hold quarterly meetings which enable each child’s case to be discussed in a timely manner (the length of the discussion may vary depending on the nature of the death in question and the quantity of information available);
- will review the appropriateness of the professionals’ responses to each death of a child, their involvement before and at the time of the death, and relevant environmental, social, health and cultural aspects of each death, to ensure a thorough consideration of how such deaths might be prevented in the future;
- determine whether or not the death was deemed preventable. The decision must be agreed by the CDOP and approved by the Chair of the CDOP. This decision cannot be finalised however until the outcome of other investigations (for example SCR’s, criminal proceedings, post-mortem or inquests) is known;
- make recommendations to the LSCB or other relevant bodies as soon as these have been decided in order that prompt action can be taken to prevent future such deaths where possible; and
- identify any patterns or trends in the local data and report these to the LSCB.
7.47 The LSCB Chair should decide who will be the designated person to whom the death notification and other data on each death should be sent. The Chair of the North East Lincolnshire Child Death Overview Panel will be the Deputy Director of Public Health. The Chair of the Overview Panel will be responsible for ensuring that this process operates effectively.
7.48 Deaths should be notified by the professional confirming the fact of the child’s death. For unexpected deaths this will be at the same time as they inform the Coroner and the person designated by the LSCB to be notified of all children’s deaths in the area in which the death occurred.
7.49 If this is not the area in which the child is normally resident, the designated person should inform their opposite number in the area where the child normally resides. In these situations it should be decided on a case-by-case basis which Panel should take responsibility for gathering the necessary information for a Panel’s consideration. In some cases this may be done jointly.
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Core Functions of the Child Death Overview Panel
7.50 For deaths occurring in an area different to that of the child’s normal residence, the LSCB for the area in which the child was normally resident at the time of death should take lead responsibility for conducting the child death review and how the other team will be notified of the outcome.
7.51 To collect a core data set of information relating to each child’s death. A data collection tool will be sent to the notifier and other key professionals. Data returned will be entered on a secure database. In addition to the core data set, for deaths requiring more in-depth review, further information will be sought from all involved agencies.
7.52 This may include: case summaries from health records; case information from police, social care and education; autopsy reports and results of further investigations; relevant information on the family and social circumstances; scene reports from police child abuse investigation units or accident investigators.
7.53 To meet on a regular basis to review specified child deaths, drawing on comprehensive information from all agencies on the circumstances of each child’s death. This information will be reviewed by the team in order to meet the objectives set out above. Whilst all deaths will be notified to the team and a core data set collected, not all deaths will be reviewed in detail.
7.54 Particular consideration shall be given to the review of sudden unexpected deaths in infancy and childhood; accidental deaths; deaths related to maltreatment; suicides; and any deaths from natural causes where there are potential lessons to be learnt about prevention. The team will determine and review on a regular basis which deaths are to be reviewed in an in-depth manner.
7.55 To receive reports from other reviews of child deaths, including individual case reviews for Sudden Unexplained Infant Death, and hospital reviews of perinatal deaths.
7.56 To review annually the numbers and patterns of deaths in North East Lincolnshire.
7.57 To notify the chair of the LSCB, the Coroner and the Police of any immediate concerns or emergency issues.
7.58 To notify the chair of the LSCB, the coroner and the police of any cases identified where there are previously unrecognised concerns of a criminal or child protection nature.
7.59 To identify any lessons to be learnt from individual reviews or reviews of overall patterns and trends, including any system or process issues and any public health issues.
7.60 To monitor professional responses to child deaths and identify good practice as well as any gaps or deficiencies in the process.
7.61 To make appropriate recommendations to the LSCB.
7.62 To provide the LSCB and constituent agencies with an annual report on the work of the team.
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Confidentiality and Information Sharing
7.63 Information discussed at the Child Death Overview Panel meetings will not be anonymised prior to the meeting, it is therefore essential that all members adhere to strict guidelines on confidentiality and information sharing. Information is being shared in the public interest for the purposes set out in Working Together and is bound by legislation on data protection.
7.64 Child Death Overview Panel members will all be required to sign a confidentiality agreement before participating in the Child Death Overview Panel. Any ad-hoc or co-opted members and observers will also be required to sign the confidentiality agreement. At each meeting of the Child Death Overview Panel all participants will be required to sign an attendance sheet, confirming that they have understood and signed the confidentiality agreement.
7.65 Any reports, minutes and recommendations arising from the Child Death Overview Panel will be fully anonymised and steps taken to ensure that no personal information can be identified.
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Child Protection Concerns
7.66 Where there is an ongoing criminal investigation, the Senior Investigating Officer and the Crown Prosecution Service must be consulted as to what it is appropriate for the Panel to consider and what actions it might take in order not to prejudice any criminal proceedings.
7.67 If, during the enquiries, concerns are expressed in relation to the needs of surviving children in the family, discussions should take place with Local Authority Children’s Social Care. It may be decided that it is appropriate to initiate an initial assessment using the Framework for the Assessment of Children in Need and their Families (2000).
7.68 If concerns are raised at any stage about the possibility of surviving children in the household being abused or neglected, the inter-agency procedures set out in Chapter 5 of Working Together 2010 should be followed. Local Authority Children’s Social Care has lead responsibility for safeguarding and promoting the welfare of children. The police will be the lead agency for any criminal investigation. The police and Coroner must be informed immediately that there is a suspicion of a crime or evidence comes to light that the death may be of a suspicious nature. This is to ensure that the evidence is properly secured by the police and the any further interviews with family members and other relevant people accord with the requirements of the Police and Criminal Evidence Act 1984. The Chair of the LSCB should be informed of the case to ensure that appropriate procedures are followed and to consider the need for a Serious Case Review.
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Taking Action to Prevent Child Deaths
7.69 The most important reason for reviewing child deaths is to improve the health and safety of children and to prevent other children from dying. The Child Death Overview Panel will maintain a focus on prevention through all its work.
7.70 Individual deaths and overall patterns of childhood deaths will be evaluated to determine if the deaths were preventable; to identify modifiable risk factors (taking account of factors in the child, the parenting capacity, wider family, environmental and societal factors, and services provided to or needed by the child or family); and to determine the best strategy(ies) for prevention.
7.71 Strategies may be considered at different levels:
- Strengthening Individual Knowledge and Skills: Assisting individuals to increase their knowledge and capacity to act leading to behaviour change, through education, counselling and individual support.
- Promoting Community Education.
- Training Providers to improve knowledge, skills, capacity and motivation to effectively promote prevention.
- Fostering Coalitions and Networks of individuals and organisations to work for advocacy and health promotion.
- Changing Organizational Practices where system failures are identified, or models of good practice highlighted.
- Mobilizing Neighbourhoods and Communities in the process of identifying, prioritizing, planning and making changes.
- Influencing Policy and Legislation where appropriate through local and national advocacy.
7.72 Recommendations made by the Child Death Overview Panel will be based on the lessons learnt from the review of child deaths, will be focused on specific, measurable actions, and will include plans for monitoring implementation.
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Working with the Media
7.73 Media interest in the work of the Child Death Overview Panel or in individual cases will be dealt with by the press officer for the LSCB. The annual report of the Child Death Overview Panel will be a public document and as such will have no identifiable information contained within. Details of individual case discussions are to be kept confidential and in no circumstances will such details be passed to the press. The LSCB press officer will work proactively with the media to promote the work of the Child Death Overview Panel alongside that of the LSCB in safeguarding and promoting the welfare of children in North East Lincolnshire.
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