11.1 Investigation of Sudden Unexpected Deaths in Childhood
This chapter was revised and updated in May 2015 and should be re-read.
- The processes described in this document pertain to the management of Sudden and Unexpected Death in Infancy and Childhood;
- The geographical location at the time of death determines the initial coronial jurisdiction;
- The protocol is not intended for the management of anticipated deaths in childhood. A weblink will direct professionals to management guidance for anticipated death;
- The protocol is not intended for the management of deaths where, whilst unexpected, arereadily apparent e.g. motor vehicle accidents;
- The guidance considers that a young person is a child until the end of the 17th year;
- Information for professionals who wish to refer families and young people for bereavement services is available at the following weblink (this link is to follow).
Objective of Guideline
- To ensure that the death of a child that dies suddenly and unexpectedly is thoroughly investigated;
- To ensure that there are clear lines of communication with the bereaved family so that they receive information about the cause of their child’s death in a timely manner;
- To ensure that professionals from all agencies have clear and agreed multi-agency procedures to follow when a child dies unexpectedly;
- To ensure that pathologists and the coroner have access to the information gathered by the multi-agency team. The information will support them in determining whether a death is from natural causes (in the majority of circumstances) or to identify the minority that are unnatural;
- Where appropriate, to protect siblings and subsequent children Agency Procedures for staff to follow on the death of a child.
A flowchart for local procedures is included as Appendix 1: Local Procedures Flowchart.
Agency Procedures for Staff to follow on the Death of a Child
The death of any child is an extremely difficult time for families and for those who have been personally or professionally involved with them. It is very important that we respond in the right way so the family feels they are supported appropriately. All necessary staff must be made aware of the situation to make sure parents and carers are not inappropriately contacted.
Child deaths can happen in a range of circumstances. Some will be sudden and extremely traumatic, while others will be expected, for example as a result of a life-limiting illness. A child may be attending an early years setting, on the roll of a Norfolk school, the subject of an SEN statement or assessment, known to social care or looked after by Norfolk or another local authority.
The Norfolk Safeguarding Children Board has a Child Death Overview Panel (CDOP) which is informed of all post-natal (0 to 4 weeks) and child (4 weeks to 18 years) deaths. The administrator for the CDOP will inform the people listed below, numbered 1 to 3, of all deaths as soon as they are known using secure methods and the actions they should take are given. The services that must be informed in order of priority are:
- Inform all Children’s Services Social Care managers and caseworkers who need to know;
- Ensure that CareFirst records are amended;
- Ensure all appropriate current procedures and protocols are followed, dependent upon the circumstances of the death, including:
- In the case of an unexpected child death the Investigation of Sudden Unexpected Deaths in Childhood policy must be followed. This includes an expectation that there should be communication and liaison between all relevant agencies including schools and Children’s Services;
- Follow the serious incident procedures if appropriate.
Children’s Services, Critical Incident Team (the team may already be involved if the child has been critically ill) who will:
- Where relevant, contact the child’s education setting to ensure they are aware of the current situation and to offer help if not already in place;
- Inform within one working day anyone in the Early Years, Schools and Communities section who has contact with the school. These may include:
- Any others as appropriate.
Note: the Critical Incident Team will inform the NSCB of their incident cover arrangements as appropriate to ensure they are fully aware of who to contact.
- Amend the Tribal Management Systems to reflect the date of death;
- Within 1 working day cascade the information to:
- Children’s Services Admissions who will:
- Ensure that staff are informed and any admissions processes currently active for the child are ended.
- Children’s Services, Operations Director who will:
- Ensure a letter of sympathy is prepared personally or by a nominated person from the child’s area/locality and sent to the Director for Children’s Services for signing.
- Children’s Services, Area/locality business admin team managers who will:
- Ensure that current records are secured;
- Appropriate area/locality based staff are informed. These could include:
- Educational Psychologist;
- Attendance Improvement Officer.
- Any area/locality processes currently active for the child are ended.
- PA to Director of Children’s Services who will:
- Expect a letter from the Operations Director to the parents expressing sympathy for signing.
- Business Intelligence and Performance: Information & Intelligence: Social Care Team who will:
- Check that CareFirst records are appropriately recording the death.
- The list of services below for their information and action if necessary:
- CS Assistant Director – Strategy & Commissioning, Safeguarding & Additional Needs;
- Sensory Support Service;
- SEN Finance;
- Parent Partnership;
- Passenger Transport section.
- Children’s Services Admissions who will:
- Keep a record of the communication noting the date the Tribal system is updated.
Please note: any person who becomes aware of a child death through means other than those noted above please contact Louise Hodgson (email@example.com) 01603 222352, Gill Williamson (firstname.lastname@example.org) 01603 222355 or Jackie Goodson (email@example.com) 01603 222585 immediately.
When contacting any of the persons listed below:
- Telephone: Only give information to those named. If they are not available please request they return your call urgently saying that it is concerning a child death. Alternatively, try another name if more than one is listed below;
- Email: firstname.lastname@example.org to email@example.com is secure and can be used when naming clients or giving their details. Where secure email accounts (.gcsx) are available these can be used with email addresses other than norfolk.gov.uk if they themselves are secure (.gsi, .gcsx, .gxs, .pnn, nhs.net). If an email system is not secure, under no circumstances name children or parents or give any details which might lead to their identification;
- Fax: Where fax machines are in open offices, please be aware that others may collect faxes so this should be used with caution. It may be appropriate to make a call to the recipient to expect a transmission.
For further information or clarification on secure email please contact ICT Shared Services (firstname.lastname@example.org).
Current Contact Details
|Please note that these are current details. Please inform the Norfolk Safeguarding Children Board: email@example.com if you cannot make contact with the identified service leads.|
|Child Death Overview Panel Administrator:|
Main contacts notified by CDOP:
|Children’s Services: Safeguarding Manager|
|Children’s Services: Critical Incident Team|
|Telephone:||Bianca Finger-Berry (firstname.lastname@example.org)
01692 502329, (07887 832413); or 07623 912977 (if urgent)
|Business Intelligence and Performance: Information & Intelligence|
Contact Details for Others:
|Children’s Services, Assistant Director (Social Care)|
|Telephone:||01603 217653 / 01603 223071|
|Norfolk SEND Partnership|
|Sensory Support Service|
The Coroner has overall responsibility for the investigation of unexpected deaths within his jurisdiction and is assisted in that process by Coroner’s Officers. In appropriate circumstances the Coroner will ask other agencies such as the Police and Health & Safety Executive to investigate sudden deaths on his behalf. The Coroners (Investigations) Regulations 2013 place a duty on coroners to inform the LSCB, for the area in which the child died or the child’s body was found, where the coroner decides to conduct an investigation or directs that a post mortem should take place. The coroner must provide to the LSCB all information held by the coroner relating to the child’s death. Where the coroner makes a report to prevent other deaths, a copy must be sent to the LSCB.
The Coroner may direct that a post mortem examination be carried out if he believes this will assist in determining how a person has died.
As a general rule, the Coroner will authorize a supervised viewing of a body to take place prior to a post mortem examination provided the Police have indicated that the death is not being treated as suspicious. The Coroner will usually open an inquest where the cause of death is unknown or is awaiting the result of further investigation. Following the opening of an inquest, the Coroner will normally release the body for funeral unless the death is being treated by the Police as suspicious.
It is for the Police to determine whether or not a death is suspicious.
The Coroner’s responsibility covers all unexpected deaths and there are no specific provisions for those relating to children.
It is the duty of the attending doctor or senior investigating police officer to inform the Coroner of all unexpected deaths occurring within his/her jurisdiction.
In cases involving the death of a child the multi-agency team will determine the most appropriate professional to share information with the family. All professionals including the coroner’s officers will liaise with the appointed professional.
It is essential that the outcome of a paediatric post mortem examination, including the cause or suspected cause of death and any related medical investigations being undertaken, are explained to the family as soon as possible. This task will be undertaken either by the lead doctor for Child Death, the appropriate consultant paediatrician ideally with the professional as the communication lead for the family.
3.1 This protocol is compliant with the National Centre for Policing Excellence CENTREX doctrine ‘Guidance on Investigating Child Abuse And Safeguarding Children’ 2005 and reference should also be made to the NPCC (The National Police Chiefs’ Council) Murder Manual.
3.2 Throughout this protocol there will be references to key tasks which officers either attending or managing the investigation will need to take into consideration.
3.3 It is important for police officers to remember that most unexplained child deaths have natural causes. Police actions therefore need to be a careful balance between consideration for the bereaved family, and the possibility that a crime has been committed.
Who should attend?
3.4 Resource deployment will be at the discretion of the Dispatch Centre and will be influenced by the location at which the apparently dead child has been reported to be. Many of these deaths will involve police attendance at Emergency (A&E) Departments, where actions will be necessarily different to those where police attend other premises. Police attendance should be kept to the minimum required. For example, several police officers arriving at a private house can be distressing, especially if they are uniformed officers in marked police vehicles. Whenever possible consideration should be given to the initial response being from plain clothed specialist officers, but this may not be possible if an emergency response has been requested. In any event, the Area Detective Inspector will be the Designated Senior Investigating Officer (SIO) in the first instance. The ongoing investigation will, in normal circumstances be managed by the Detective Inspector, Child Abuse Investigation Unit If subsequent assessment considers the death to be suspicious then out of hours the on call Force SIO will be contacted and take the lead role in the investigation assisted by the D/Supt or D/CInsp. If the death is within office hours the Child Abuse Investigation Unit Detective Inspector will contact the Area Detective Superintendent, Joint Norfolk and Suffolk Major Investigation Team who will take the lead role. The on call SIO can be contacted at all times for advice.
Samples and Pathology
3.4.1 In all cases the police should request for the post mortem to be undertaken by a paediatric pathologist or a pathologist who has paediatric expertise. If the death is felt to be suspicious then the Home Office pathologist should perform the post mortem and if he/she lacks paediatric experience then he/she should be encouraged to work alongside a paediatric pathologist to maximize the opportunity for recovery and interpretation of evidence.
3.4.2 Good co-operation between the police and the paediatrician is very important. The paediatrician will carefully follow the protocol to ensure that a thorough external examination is undertaken together with relevant investigations. However, prior to any examination or samples being taken by the paediatrician where the death is suspicious there must have been a discussion and agreement with the SIO and HM Pathologist. Furthermore for suspicious deaths agreement must be reached as to where the body will go for the post mortem and samples. The SIO will contact the Acute Paediatrician on call and contact the HM Pathologist through the Contact and Dispatch Team.
3.5 Where the deceased child is at an Emergency (A&E) Department, consideration must be given to the deployment of resources at the address from which the child came, prior to its attendance at Emergency (A&E) Department. Officers maintaining the integrity of any such scene should use unmarked vehicles where possible.
Initial action at the Scene (other than at Emergency (A&E) Department)
3.6 The first priority (as in any such case) will be the provision of medical assistance to the child.
3.7 If an ambulance is not present one must be called immediately, and consideration given to attempting to revive the child, unless it is absolutely clear that the child has been dead for some time. (Ambulance Service Personnel will remain on scene until their release is confirmed by the Designated SIO).
3.8 Officers in attendance will need to show compassion and sensitivity. Careful thought needs to be given to the use of police radios and mobile telephones. Police terminology such as “scene of crime” should be avoided. Good practice is to establish and use the child’s name whenever referring to the child.
3.9 The Area Detective Inspector will attend as the Designated SIO. Amongst other considerations, he/she will:
- Consider release of Ambulance Service Personnel and vehicle as soon as possible;
- Ensure arrangements are made to secure all relevant documentation;
- Make contact with the Multi-Agency Safeguarding Hub (Or, out of hours, the Duty Vulnerability and Partnerships Duty Detective Sergeant and Social Services Emergency Duty Team) to commence background searches and information to enable a full picture of the circumstances to be examined at the earliest stage;
- Arrange liaison with Children’s Services to prompt a strategy meeting.
3.10 The Coroner’s Officer must be notified as soon as possible. The SIO and the Coroner’s Officer should continue to liaise closely throughout the investigation.
3.11 An explanation should be given, where appropriate, to the parents/carers that police attendance at such deaths is routine in order to try and determine how the child died. This will include giving an understanding of the need, in some cases, to secure items from the location of the child’s death and the taking of photographs to support the process towards providing the most comprehensive understanding of the cause of the death.
3.12 An early record of events from the parents/carers is essential, including details of the child’s recent health. All comments should be recorded. Any conflicting accounts should raise suspicion but it must not be forgotten that any bereaved person is likely to be in a state of shock and possibly confused. Repeated questioning of the parents/carers by different police officers and other professionals should be avoided at this stage if at all possible.
Initial action at Emergency (A&E) Department
3.13 The SIO will attend the Emergency (A&E) Department as soon as practicable in order to consult with the Senior Paediatrician in order to jointly review the presenting information and to consider the appropriate course of action.
3.14 Issues such as handling of the deceased child will require particular care and sensitivity. There should be minimal handling by medical staff only until a full assessment of the situation can be made by the SIO in conjunction with the Senior Paediatrician. This should include a discussion about offering parents a lock of hair, hand or foot print or other memento.
3.15 In any event, the deceased child must not be removed from the Emergency (A&E) Department until after the SIO/Senior Paediatrician have had their joint discussion.
3.16 During this joint discussion consideration will be given to forensic and pathology issues which will include retention of the deceased child’s clothing and, in particular, any nappy and contents.
3.17 If the child has been certified as deceased then details of the person declaring death must be obtained as well as the relevant time. Similarly, details of any Ambulance Personnel or method of transport of the deceased child to the Emergency (A&E) Department, together with what sort of medical intervention or assistance attempted, must be established for the information of the SIO.
3.18 Attendance at the Emergency (A&E) Department should be kept to a minimum and consideration must be given to preserving any other place as a potential scene of where death occurred. Similarly the advice at Section 3.3 above will apply.
3.19 The preservation of the scene and the level of investigation will be relevant and appropriate to the presenting factors.
3.20 Officers initially attending the scene should ensure it is preserved until such time as the SIO gives any further instruction. Any relevant items should be drawn to the attention of the SIO, who will assess the circumstances and information available. Additional resources such as photographers will be considered at this stage and the SIO will decide what items, if any, will be retained or removed from the scene. It is important to look at the scene of death as an important opportunity to help understand the death in the absence of any obvious concerns. The information will be used to support the medical understanding and in certain cases may lead to the development of future Child safety strategies through the Norfolk Safeguarding Children Board.
3.21 If it is necessary to remove items, this will be done with due consideration for the parents/carers, who should be asked if they want the items returned.
3.22 If parents/carers ask to hold the deceased child this can be permitted but should be done with the knowledge of the SIO and in the presence of a Police Officer or other professional.
3.23 In all cases H.M. Coroner will be kept informed of the progress of the investigation and issues for consideration will include:
- Completion of Sudden Death A42 document;
- Continuity of identification of the deceased child;
- Attendance at post-mortem examination;
- Tissue and organ retention. (With reference to the duties under the Human Tissue Act 2004).
Away from the Scene
3.24 In all but exceptional circumstances (e.g. at a suspicious child death police response will be in accordance with the NPCC Murder Manual) the body of the deceased child will be conveyed by Ambulance to the relevant Emergency (A&E) Department (i.e. not to the mortuary).
3.25 If the parents/carers wish to accompany the child’s body from the home to the Emergency (A&E) Department, then this should be facilitated.
3.26 The SIO or his/her nominee will continue to maintain contact with the family and keep them informed of any developments throughout the process. It will be a matter for the SIO to direct the use of Family Liaison Officers (NPCC M.I.M). or to facilitate the contact using trained Family Contact Officers through the Vulnerability and Partnerships Command. This will usually be dictated by the nature of the enquiry.
In order to coordinate information shared with the family an appropriate professional will be nominated by the multi-agency team (see Process for multi-agency response to the unexpected death of a child or young person Working Together flowchart and Appendix 1: Local Procedures Flowchart). The SIO or nominee may wish to communicate directly or via the appropriate professional (and in some cases will be the appropriate professional).
Initial Strategy Discussions
3.27 The SIO will attend the Initially Strategy Discussion in accordance with the joint agency protocol. This meeting will look at the initial circumstances around the death allowing each agency to share the information held in relation to the child and family. The meeting will look at the future contact with the family and, in appropriate cases, a planned understanding as to how the information will flow to the family as it becomes known. This will ensure that the right support can be provided to support their understanding. This is particularly important in terms of understanding the wider background picture around the child, protection of siblings and sharing medical outcomes.
3.28 Around 8-12 weeks after the child’s death a further inter-agency case meeting should be held to review the findings of the post-mortem report and any other information gained about the child, their family and circumstances leading to the death. When appropriate, this meeting will mark the closure of the investigation into the child’s death. This meeting should be arranged by Social Care Services, following consultation with the Police and will be dependent on the progress of the Police/Coroner’s investigations.
3.29 At the earliest opportunity after enquiries are completed, (after consultation with the Coroner’s Officer), any items the family wish to have returned, should be returned to them.
3.30 All police documentation will be removed and the property will be returned if appropriate in new/clean wrapping/bags. If soiled articles were taken, parents/carers should be asked about their return, and if they would like them cleaned prior to return.
3.31 An appointment should be made with the parents/carers to return any property, remembering that this could be a significant event for them. This will be undertaken by the Contact Officer or Family Liaison Officer who will be trained for this purpose.
Occasionally the GP is the first professional to attend the scene of an Unexpected Death in Childhood and in general the same guidance applies to GP as the ambulance service.
It is important that if the GP is first at the scene and that they take responsibility for contacting the Police and the Coroner’s Officer via Police Headquarters.
The GP may not issue the death certificate under these circumstances.
Even if the GP determines that the child has died it is important that the body of the child is taken to the A&E department and not to the mortuary.
If the GP decides to pronounce death he/she should consult with the senior police officer present before allowing the Ambulance Service to remove the body of the child to the hospital.
The primary healthcare team (GP and Health Visitor) has an important responsibility to support the family and liaising with the hospital medical staff.
If the mother of the child who has died is breast feeding consideration should be given to offering medication for suppression of lactation.
If you are first at the scene:
(No change from previous protocol 5.1)
If you learn that a child has died:
- Inform the Safeguarding Children Team/Team leader of the appropriate community trust who will liaise with others e.g. communications department when necessary);
- Inform the Child Health Department that the child has died (ECCH Safeguarding Team will inform the Child Health Department). This is to ensure that reminders for immunizations etc are cancelled;
- Liaise with other professionals as appropriate to determine who will make arrangements for support of the family. Bereavement support and follow up care will be decided at the initial information-sharing meeting. Health visitors are not responsible for informing other agencies (e.g. schools);
- Verify details of identification of the child and record on SystmOne;
- Health visitor to arrange clinical supervision for personal/professional support.
The full guidance for ambulance staff is outlined in the document “UK ambulance services clinical practice guidelines 2013”.
Calls will be received and triaged in the local Health and Emergency Operations Centre (HEOC). An emergency response will be dispatched in line with standard protocols.
If child cardiac arrest or possible death is identified at the call handling stage then the team leader or duty manager will alert the police. The police CAD reference should be recorded in the ambulance CAD log notes.
On arrival of the emergency response the child will be resuscitated in line with paediatric basic and advanced life support guidelines unless there is a condition unequivocally associated with death.
The child will not be moved if there is evidence of a condition unequivocally associated with death.
The attending crew will observe the scene and these details will be recorded in the patient record.
If resuscitation is commenced the child will be transported to the nearest emergency department with ongoing resuscitation.
If the child is being resuscitated HEOC will inform the police of the clinical situation at the destination of the child.
If the child is pronounced dead at the scene the attending crew will wait on scene and liaise with attending police officers.
If requested by police the ambulance crew will remain on scene until such time as the police have completed their investigation to the point where the body can be moved from the scene unless they are stood down by the police force.
When given permission by the police the dead child and their parents will be transported to the nearest emergency department. Whether the child is being resuscitated or has been pronounced dead at the scene parents will be transported with the child unless there is instruction from the police not to do so.
If the ambulance service is requested to attend a scene by the police to remove the body of a dead child this will be treated as a priority but the journey will not be undertaken on blue lights.
In all instances of child death or child resuscitation the ambulance crew will pre-alert the receiving hospital’s emergency department.
If taking the body of a child to the nearest emergency department means that a county boundary will be crossed this should be discussed with the attending police officer.
In all instances where crews have been involved with a child death this will be reported through our single point of contact to ensure that any surviving children are supported through the grief process.
The Rapid Response Team for Unexpected Child Deaths is a multi-agency team. In Norfolk the team is made up of specially trained nurses, doctors and police officers.
The remit of the team is to facilitate information gathering to determine the cause of the unexpected death of a child.
The decision to request a Rapid Response visit should be made at the first multi-agency discussion and involve the hospital team, the police, Norfolk Children’s Services and when possible the Rapid Response team representative.
When possible an initial interview with the family should take place prior to the visit. This should involve the members of the RRT that will undertake the home visit. (This initial meeting with the family should, when possible, be undertaken at the same time as other history-taking activities so that the family is not expected to recount the events of their child’s death several times).
Following the RRT visit a report will be prepared and the information should be shared with:
- CDOP co-ordinator;
- Norfolk Children’s Services;
- And also with Designated team for Safeguarding Children Norfolk and Waveney.
It may be appropriate to share information with e.g. the police immediately and prior to the preparation of the report.
The RRT will attend the Initial Information Sharing and Planning Meeting.
This guidance should be used in conjunction with the agreed hospital policies and procedures for when a child or young person dies unexpectedly.
In most circumstance the child’s body will be brought to A&E, suddenly and unexpectedly prior to their 18th birthday. If the police feel that the death of the child is suspicious they will determine where the body of the child is taken.
All family members will be dealt with in a sensitive manner with early involvement of Senior Medical Staff, (usually the on-call Acute General Paediatrician). Careful recording and documentation of the history, examination and appropriate investigations underpins the process. In some circumstances, a child is revived by resuscitation efforts, but subsequently dies. In these cases, it is still appropriate to use the SUDIC documentation. Following the sudden unexpected death of a child (17 years old, or younger), the Responsible Consultant will be the on-call acute general paediatrician on-call (for children under 16) or the SUDIC consultant.
The Bereaved families are offered optimal support during a traumatic time. A thorough inquiry into child’s death is performed, with emphasis on history, examination and investigations. Pathologists and the Coroner have access to information which will assist them in accurate determination of the cause of death. The welfare of siblings and subsequent children is safeguarded, whatever the cause of death.
Every sudden unexpected death in childhood should prompt a multi-agency investigation including Health Professionals. This applies to children and young people up to the end of their 17th year.
Informing the Family of Death
Following cessation of resuscitation and when death has been pronounced by an experienced Paediatrician will share this information with the bereaved family. The interview should take place in a room or area that offers the family privacy. A senior police officer and/or a member of the Rapid Response team may also be present. It is important that the family are treated with respect and dignity irrespective of the circumstances of the child’s death.
The family should be informed of the requirement for a post mortem and also for the need for the hospital team to work closely with a number of other professionals including the coroner, the police, Children’s Services and the family’s GP. If it is anticipated that the family home will be visited by the Rapid Response Team this information together with an explanation of the purpose of the visit should be shared with the family at this point.
If the deceased child is a baby and if the mother had been breast feeding she should be offered treatment for suppression of lactation.
In consultation with the Senior Investigating Officer (police) the body of the child will be carefully examined and appropriate photographs obtained if necessary. It is important that this process is undertaken in consultation with the police and it is at this time that there is a discussion with police with regard to taking mementos such as a lock of hair or hand or foot prints.
An initial multi-agency discussion will take place between the senior paediatrician, the police, Norfolk Children’s Services and a member of the Rapid Response Team (if available) to determine whether a Rapid Response visit is appropriate and to determine the timing of the visit. It is at this initial multi-agency discussion that tri-partite discussion for the need for a safeguarding strategy meeting will occur.
The hospital team, with agreement from the police (and coroner when appropriate), should undertake their procedures including investigations to determine a medical cause for the death.