11.1 Managing Child Deaths

This policy has been updated to reflect the changes to the Children’s Advice and Duty Services (CADS) that comes into effect from 17th October 2018.

The following policy outlines the local procedures for the implementation of processes outlined in Regulation 6 of the Local Safeguarding Children Board Regulations 2005 and Chapter 5 of Working Together to Safeguard Children 2018.

Acknowledgment and thanks to the Southend, Essex and Thurrock LSCBs for sharing their best practice with Norfolk.

This policy should be followed by professionals in conjunction with all relevant policies, procedures and protocols from within their own agencies.

This chapter was revised and updated in September 2018.

1. Introduction

    1.1. Scope

    The policy applies to the death of any child under 18 years or where there is reason to believe they are likely to be under 18 years old whether from natural, unnatural, known or unknown causes, at home, in hospital or in the community and whether expected or not. The scope should include children who normally reside in Norfolk or who may have died abroad or in other areas of the country. Stillbirths and deaths resulting from planned termination of pregnancy carried out within the law are excluded from this process.

    All deaths will be subject to a child death review by the Norfolk Child Death Overview Panel (NSCB CDOP) but only unexpected deaths will be subject to a joint agency rapid response.

    The disclosure of information about a deceased child is to enable the NSCB and its partner agencies to fulfil statutory requirements related to child deaths.

    The policy is based on statutory guidance as referenced at the end of this policy and includes:

  • Children Act 2004 (the Act) as amended by section 24-28 of the Children and Social work Act 2017
  • Child Death Review Statutory Guidance, 2017
  • Working Together to Safeguard Children, 2018
  • Sudden Unexpected Death in Infancy and Childhood; multi-agency Guidelines for Care and Investigation, 2016.

    1.2. Key principles

  • to ensure a thorough, systematic and sensitive approach is undertaken to establish, as far as possible the cause(s) of the child’s death focusing on history, examination and investigations, and to identify any potential contributory factors;
  • to ensure bereaved families are offered optimal support during a traumatic time, and that sensitivity is maintained alongside objectivity toward the cause/s of death;
  • to ensure the safety, wellbeing and welfare of siblings, any other children associated with child, and subsequent children;
  • gather information for the NSCB Child Death Overview Panel (CDOP);
  • to preserve evidence;
  • to identify learning.

    1.3. Categories of death

    This policy covers all categories of childhood death, including:

  • unexpected deaths from natural causes and from external causes (accidents, homicide, suicide);
  • expected deaths.

    1.4. Definitions

    1.4.1. Unexpected death

    An unexpected death is defined as the death of an infant or child (anyone who had not yet reached their 18th birthday) which;

  • was not anticipated as a significant possibility for example, 24 hours before the death or;
  • where there was an unexpected collapse or incident leading to or precipitating the events which led to the death. (Working Together to Safeguard Children, 2018)
  • The second part of this definition is especially relevant when there is a significant time delay between the collapse of the child and their eventual death.

    1.4.2. Expected death

    An expected death is defined as the death of an infant or child which was anticipated following on from a period of illness that has been identified as terminal, and where no active intervention to prolong life is ongoing.

    It is expected that children with a life limiting or life threatening condition will die prematurely although, it is not possible to anticipate when, or in what manner they will die.

    2. Unexpected death – pathway one


  • unexpected
  • unexplained cause
  • overt trauma
  • expected death where coroner or police involvement may be required when a medical outcome that is precipitated by an unknown event or perhaps a medical causation that can be historically traced back to non-accidental injury.

    2.1. Initial response to an unexpected child death out of hospital

    On receipt of a call regarding a dead or moribund child the ambulance control centre should contact the Norfolk police control room on 101 to inform them.

    The police initial responders should attend the scene, assess if there are any suspicious circumstances and deal with the death, in-line with sudden unexpected death police policies and procedures.

    The police control room should inform the MASH police/Children’s Advice and Duty Service (CADS) who will undertake multi-agency information sharing and checks on family and siblings.

    Ambulance service, police and other professionals attending the scene should attempt resuscitation unless clearly inappropriate and the child should be transferred to an emergency department prior to their death being declared. However, where resuscitation is clearly inappropriate, the death can be declared at the scene by an appropriately qualified professional but the child/young person should still be transported directly to the local emergency department.

    Every effort should be made to preserve the scene of the death/collapse pending the rapid response team visit. Information about the scene and any concerns about the death should be passed on to the police in attendance and to the receiving doctor at the hospital.

    All professionals in attendance should record, using standard agency processes and forms, the circumstances of how the child was found and any information provided by the parents/carers or surmised from their actions, appearance or living conditions that may be of help in explaining the circumstances of the child’s death/collapse. (This information should be provided to the rapid response team/CDOP and Police).

    If the child is declared dead at the scene, the professional declaring the child’s death is responsible for identifying anything about the child’s death which gives cause for concern or suspicion.

    Examples of circumstances where it may not be immediately appropriate to transfer a child to the emergency department are because scene of crime officers need to complete their work;

  • if the child has obviously been dead for some time when found;
  • the circumstances of the death mean the body must remain at the scene for forensic examination; or
  • there is significant trauma to the body as a result of fire or other major incident.
  • For an unexpected death, the declaring professional will normally be an Accident and Emergency (A&E) consultant, paediatrician or, in very exceptional cases, the paramedic.

    The child should be transported to the emergency department along with representatives of the child’s family unless they make their own arrangements to reach the hospital.

    2.2. Unexpected child death in hospital setting

    For an unexpected child death in a hospital setting hospital staff should work in accordance with in house procedures based on national guidance (Initial assessment of an infant or child (under 18 years) presenting unexpectedly dead or moribund) Appendix 1. The rapid response team must be contacted and the death will be subject to a joint agency rapid response.

    2.3. Initial assessment on arrival A&E

    2.3.1. Examination

    On arrival at a hospital, the initial examination of the child should be undertaken by the most senior paediatrician available (ST4 or above) with the lead police investigator present. All hospital staff should work in accordance with the Clinical Guidance for Management of Sudden Unexpected Death in Infancy and Childhood (SUDIC) Appendix 1. This is standardised guidance across the three Norfolk acute hospital trusts.

    2.3.2. Kennedy samples

    As soon as possible after the death Kennedy sampling should be taken in accordance with the acute hospital SUDIC policy (Appendix 1).

    Samples taken for resuscitation purposes may be used if the resuscitation attempts are unsuccessful, but they may not meet all the requirements of Kennedy sampling. In the rare instance that Kennedy sampling may be deemed inappropriate this should be agreed with the paediatrician and police and the rationale documented clearly.

    It is important to note that after death, consent for Kennedy Samples is the responsibility of the coroner, not the parents/carers and established arrangements are in place with the coroner for the consent and collection of Kennedy samples to take place in all cases.

    Parents/carers should have the process for taking samples and the coroner responsibility for consent explained to them. Consent to retain samples beyond the period required by the coroner must be sought from those with parental responsibility for the child in accordance with agreed procedures.

    Where any samples taken from the child produce an anomalous or concerning result, it is the responsibility of the paediatrician to inform the police at the earliest point. Any delay in obtaining samples and acting on unexpected results may impact on agencies’ ability to safeguard other children and other crucial decisions.

    2.3.3. Skeletal surveys

    For most children under the age of two a skeletal survey should be undertaken, if there is any suggestion of a suspicious cause of death. Consideration should also be given to undertaking a skeletal survey for children over this age, when circumstances are suspicious, i.e. of non-accidental injury. The survey will be undertaken at the place of post-mortem. If it is suspected that the child has been subject to non-accidental injury and there are other children in the household who may be at risk and waiting for the post mortem could lead to unacceptable delay (more than 24 hours), arrangements should be made, following discussion with the coroner and the radiology department, to undertake the survey on-site within working hours.

    2.3.4. Clinical photography

    Consideration should always be given, where possible, to the taking of photographs of the child’s body for the purposes of informing future discussion regarding the cause and time of death. If the death is being treated as suspicious these photographs should be taken by a police photographer. Photographs should be taken and stored and consent obtained in accordance with agreed hospital trust and police procedures.

    2.3.5. Care of child’s body and personal items

    Any clothing removed from the child and any items of clothing or bedding brought in with the child should be retained by the police and should not be returned to the family without the agreement of the coroner. The child’s body should not be cleaned as this may interfere with the pathologist’s investigations, however the child may be wrapped in a clean blanket. If cleaning of the body is deemed essential, the consultant paediatrician and police should be consulted and photographs or swabs should be taken prior to the cleaning occurring. If the parents/carers have asked to see their child’s body and it has not been cleaned, this, and the reasons for it, should be explained to them.

    2.4. Initial information sharing and planning meeting (within first 2 hours of arrival at the hospital)

    An initial information sharing and planning discussion should take place before the family leave the emergency department. This will be co-ordinated by the most senior paediatrician present. Decisions should be recorded in the child’s records.

    At a minimum this meeting should include the senior paediatrician, lead police investigator, rapid response nurse and, the hospital safeguarding team in working hours. The lead police investigator should ensure that back ground information is sought from children’s social care prior to this meeting.

    The children’s social care information will add to both police and medical information to underpin further planning and investigation. Information from the ambulance crew should also be obtained.

    The discussion should include when to undertake a visit to the place at the child’s home or where the child has died.

    Agreement should be reached at the meeting by the paediatrician and the police investigator about the taking of hand and foot prints and opportunities for parents/carers to hold their child. Delays in allowing this should only occur where the police are considering conducting a criminal investigation.

    The death of a child is likely to have a far wider impact than the immediate family and may include friends and peer groups in education settings. It may also extend to education settings attended by siblings. Therefore, the police should seek consent from parents or carers to inform children’s social care critical incident lead to ensure that there is a coordinated and timely process to inform the education setting/s and agree arrangements for communicating and providing advice and support to staff and pupils.

    If the family does not consent to such information sharing, the critical incident team should jointly agree with the police as how to proceed and the agreed processes and rationale needs to be recorded. The police and children’s social care will need to assess the welfare needs of other children in determining this. In all circumstances, the information to be shared with the education setting at this stage should, at the very least, be limited to the notification of the child death. There should be an agreed and clearly recorded record outlining the information to be shared and with whom this information can be shared with.

    The notification of child death should be completed using the following link: https://www.ecdop.co.uk/NorfolkSuffolk/Live/Public at this initial meeting by the multi-agency rapid response team and sent to the CDOP administrator and agreement reached around notification to the wider NHS and partner agencies.

    2.5. Post death discussions with parents/carers

    The paediatrician should discuss the following points with parents/carers:

  • The next steps in the child death review process including a home visit/visit to the scene of the death (parents/carers should be asked not to disturb the room/scene in which the child died until this visit is carried out).
  • The future involvement of professionals including the police, the coroner and the health rapid response team (RRT).
  • Details of relevant support agencies and a copy of the NSCB child death review leaflet for parents and carers.
  • Information about what will happen to their child’s body including taking samples, post mortem, release of the body for the funeral, the opportunity to see, hold and take mementos from the child (hand and footprints, etc.)
  • Where a child’s death had been expected but their life limiting condition is as a result of a non-accidental injury, discussions should/should have taken place between the police and the family/carer regarding the need for SUDIC investigations. This will include an agreement on the timings of police involvement, the method of the introduction and the explanations that should be offered to parents or carers in advance of the death.
  • Parents/carers should be provided with the opportunity to ask any questions that they have at this stage and should be told who they can refer future questions to. They should also be offered assistance in contacting other family members, friends, the hospital chaplain or other religious leaders as required.

    Any further information obtained during this conversation about the circumstances of the child’s death should be recorded and provided to the police by the paediatrician or other relevant professional.

    2.6. Visit to the scene of the death and home visit

    This visit will be undertaken by the police officer and health RRT within 24 hours. Arrangements to undertake the visit will involve discussions with the parents/carers and/or other appropriate persons (e.g. house or premise owner) if the death did not occur in the family home.

    Information collected at the scene visit should be summarised into a report by the health RRT and police and then forwarded to the coroner’s officer, pathologist, CDOP administrator and Designated Safeguarding Children Team and copied into the child’s records – both paper and electronic.

    The rapid response process will to be applied to all unexpected deaths of children; however, it is recognised that there are some limited circumstances in which following the rapid response process in its entirety would be inappropriate. Decisions should be made on a case by case basis and where there is uncertainty a consultant paediatrician must be consulted. Further guidance has been provided in the Royal College Pathologists (RCP) and Royal College of Paediatricians and Child Health (RCPCH) multi-agency guidelines for sudden unexpected death in infancy and childhood November 2016.

    2.7. Multi-agency strategy meeting (on the day of the child’s death)

    Where a death is unexpected, a multi-agency child death strategy meeting will be convened on the day of the child’s death under Section 47 of the Children Act 1989. The meeting will be chaired by the children’s social care head of social work. However, if the death occurs out of hours, a strategy meeting will be convened by the Emergency Duty Team (children’s social care EDT) with a second strategy meeting convened on the next working day chaired by the children’s social care head of social work.

    The purpose of the meeting is for agencies to ensure a coordinated response to support parents/carers/siblings, share information, consider any safeguarding risks to siblings or other children associated with the family and ensure a coordinated plan to support peers and education settings. It is also essential to consider the impact of media interest.

    2.8. Child death review meeting (within 2 working days of the child’s death)

    The hospital safeguarding team will arrange a child death review meeting within two days of the initial strategy meeting. The meeting will be chaired by the consultant paediatrician or the designated doctor for child deaths. The purpose of the meeting is to review all information obtained since the child’s death and any new information which may be available from initial post-mortem findings. The outcomes of this meeting should be captured in Form B, and minutes from this meeting should be recorded and sent to the coroner, pathologist, all agencies involved in the meeting and the CDOP administrator. On conclusion of this meeting a final child death review meeting date should be agreed and arranged and the membership of this meeting confirmed.

    All agencies identified including voluntary services as having relevant information will be requested to complete a Form B which will be sent out by the CDOP administrator. On receipt of the Form B, the professionals should review all records on the child and the family available to them and complete those parts of the form that are relevant to their agency/profession. Information from health, police and social care records should be obtained prior to a post mortem being undertaken; information from other agencies may not need to be obtained with such urgency depending on the individual circumstances of the death. This meeting should also agree a date for the final child death review meeting.

    2.9. Post-mortem (PM)

    Where appropriate, the coroner will order that a PM is undertaken on the child. On completion of the PM, the initial results will be provided by the pathologist to the coroner (results of histology, toxicology etc. will not be available at this stage). In the event of any irregular findings the coroner may direct other action including the consideration of a police investigation or the involvement of a forensic pathologist.

    The coroner will release the initial PM results to the police and the consultant paediatrician. PM results are highly confidential and should only be shared after permission has been granted by the coroner. Any information from the PM provided to the bereaved parents or carers of the child should be managed via the consultant paediatrician. Some results from the PM will become available at a later stage as some investigations can take a number of weeks to complete. The final results of the PM will be forwarded to the CDOP administrator and consultant paediatrician and the results will be explained to the parents or carers in person by the consultant paediatrician. If requested, the results can also be sent the parents/carers by the coroner or consultant paediatrician.

    2.10. Child death review meeting (6 to 8 weeks after the child death)

    The hospital safeguarding children team will convene a further meeting 6 – 8 weeks after the child’s death to provide an opportunity to discuss the case again and review any further information gained in respect of it. The hospital safeguarding team will work with the CDOP co-ordinator to identify who should be invited. The meeting will be chaired by the designated doctor for child deaths supported by the consultant paediatrician and the hospital safeguarding team and the health RRT. Representation will include professionals involved in the care of the child, including children’s social care, education settings, early years, health, voluntary sector etc.

    The meeting will ensure key agencies come together to review support for the family, consider best practice, provide feedback to those involved, consider any information that may be required by the police or coroner if an inquest is required and provide any recommendations for CDOP as per the guidance in the Child Death Review Statutory Guidance, 2017. The meeting will also identify any modifiable/ contributing factors and consider any lessons to be learned

    At the meeting it must be agreed what information should be shared with the parents or carers of the child and how this information will be provided to them.

    2.11. Child death review meeting with parents/carers – 6 to 8 weeks after the child death

    The consultant paediatrician and any relevant health professionals will offer to meet with the parents/carers after the child death review meeting. The purpose of the meeting will be to discuss the cause of death, respond to the family’s questions or concerns and identify any additional support required by the family.

    3. Expected death – pathway two

    3.1. Initial end of life care planning meeting preceding the child’s death

    An initial planning meeting for end of life care should be convened and chaired by the consultant paediatrician. Representation should include relevant nurse specialists, nurses, allied health professionals, children’s social care, East Anglia’s Children’s Hospices (EACH), educational setting, critical incident lead officer, general practitioner, parents/carers and any other relevant professionals. The relevant professionals will be invited to further meetings including initial information sharing and gathering meetings and child death review meetings. The purpose of the meeting should be to coordinate care of the child and family, to ensure appropriate symptom management, develop an end of life care plan including resuscitation plans and to coordinate communication and liaison with other professionals such as ambulance etc. At the meeting the consultant paediatrician should agree the frequency of on-going end of life care multi-disciplinary meetings. A key worker for the family should be identified and agreed (first point of contact) and the plan should include, emergency telephone numbers, personnel responsible for verification and certification of death.

    3.2. Initial response to an expected child death at home, a hospice or a hospital

    The child may be declared dead in situ and will not normally be resuscitated or transferred to an A&E department. Death may be verified by a trained professionals such as an EACH nurse/clinical nurse specialist. Ambulance and police will not attend an expected death unless suspicious circumstances are identified.

    It is the responsibility of the GP/other professional declaring the death of a child to make a notification if required, to the coroner. It is important that GPs and other medical professionals are aware of the causal history of the child’s medical condition prior to completing a Medical Certificate of Cause of Death (MCCD). If necessary the child’s consultant paediatrician should be contacted for advice.

    Professionals need to make reference to end of life plans, particularly if the life limiting condition is a result of injury sustained earlier in childhood. In these cases, the plan should include coronial and police engagement.

    The GP or other declaring professional is responsible for notifying the death to the CDOP administrator by completing the online notification form. The coroner’s office should check with the CDOP administrator that a notification has been submitted by the GP or other declaring professional.

    3.3. Initial information gathering and sharing meeting (within one working week)

    The meeting should be convened by the lead professional (e.g. hospital paediatrician, hospice, GP). The purpose of the meeting is to coordinate support to the family, coordinate information sharing, complete Form B or agree time for its completion, coordinate support and debrief to the team involved in the care of child, coordinate notifications to other organisations. The minutes of the meeting should be should be sent to all agencies involved in the meeting and the completed Form B should be sent to the CDOP administrator. On conclusion of this meeting a final child death review meeting date should be considered for 6 to 8 weeks and the lead professional/membership of this meeting agreed.

    3.4. Post death discussions with parents/carers

    The lead professional should discuss the following points with parents/carers as follows:

  • opportunities to hold their child;
  • have relatives or friends contacted if requested;
  • opportunity to collect mementos, such as a lock of hair, photograph, hand and footprints etc;
  • details of relevant support agencies and a copy of the NSCB child death review leaflet for parents and carers should be made available.

    3.5. Child death review meeting: 6 to 8 weeks after the child’s death

    The designated doctor for child death will chair this meeting. Clear guidance has been provided regarding the purpose and structure of these meetings in accordance with the Child Death Review Statutory Guidance, 2017. This meeting will provide an in depth discussion regarding the child’s death and events leading up to it. This meeting will also inform discussions with parents.

    3.6. Child death review meeting with parents/carers – 6 to 8 weeks after the child death

    The lead professional will offer to meet with the parents/carers 6-8 weeks after the child’s death. The purpose of the meeting will be to respond to the family’s questions or concerns and identify any additional support required by the family and to discuss the cause of death.

    4. General guidance

    4.1. Child Death Overview Panel (CDOP)

    All child deaths are subject to a multi-agency review by the CDOP. The purpose of the CDOP is to review information on all child deaths to inform local strategic planning, identify any modifiable/ contributing factors and consider any lessons to be learned.

    CDOP provides independent scrutiny of each child death from a multi-agency perspective and differs from the child death review meeting in that the information is anonymous and the panel is made up of senior professionals who have had no involvement in the case.

    CDOP has a specific responsibility to consider whether each death falls into a category whereby a serious case review would be a requirement and, if they identify a case to refer, to consider why this has not been done previously.

    Any professional who becomes aware of a death of a child which they believe has not already been appropriately notified should contact the CDOP administrator and complete a notification using the following link: https://www.ecdop.co.uk/NorfolkSuffolk/Live/Public.

    Notifications should include children normally resident in Norfolk who may have died abroad or in other areas of the country.

    4.2. Serious Case Review (SCR)

    Serious case reviews are statutory reviews conducted by LSCBs when a child has died and abuse or neglect are known or suspected to be factors within that death.

    If at any stage in the review of a child’s death information arises that suggests that the above circumstances apply then the CDOP administrator should be alerted who will then liaise with the relevant partner(s) regarding referring the case for consideration of an SCR.

    4.3. Serious incident procedures

    In addition to following the processes outlined in this policy in respect of child deaths all agencies should also follow their nationally and locally agreed procedures for reporting and handling serious incidents. This includes serious childcare incidents, serious untoward and patient safety incidents.

    Where notification of an incident results in a local or external review or investigation being undertaken the results of these investigations should be made available to CDOP and will be used to inform the child death review. The findings of the rapid response and CDOP cannot be finalised until these reviews are concluded.

    4.4. Cross border issues

  • Children dying in Norfolk who are not normally resident in Norfolk
  • Children normally resident in Norfolk dying elsewhere
  • Following the initial response and on receipt of a death notification for a child not normally resident in Norfolk, the CDOP administrator should make contact with their counterpart for the area where the child is normally resident. An agreement should then be reached on who should take the on-going responsibility for the review. Liaison should occur between the relevant designated professionals to inform this decision making.

    Decisions on who should take responsibility for the review following the initial response should be made on a case by case basis. For most accidental deaths occurring in Norfolk to non-Norfolk resident children it would be expected that the NSCB will lead the review of the circumstances of the incident. However Norfolk would rely on the area where the child was normally resident to undertake a full review of the case incorporating all background and historical information held within the area in relation to that child. Norfolk would expect the reverse to apply for deaths of a Norfolk resident child occurring out of county due to the incident happening elsewhere.

    Should a child normally resident in Norfolk die elsewhere in the UK it is expected that contact will be made with the Norfolk CDOP administrator by the Board for the area in which the child died. Information will be obtained as to the rapid response that has already been undertaken by that area and of the circumstances of the death. A decision will be made by the CDOP administrator in conjunction with the designated professional and the other Board regarding the transfer of review of the case to Norfolk. The CDOP administrator should make the necessary arrangements to obtain the relevant records and paperwork from the other Board.

    Decisions made on which Board should have responsibility for the review should have regard to the area in which any inquest is to be held and consultation with the coroner should form part of the decision making process.

    In some circumstances reviews may be undertaken jointly by both Boards in which case, feeding back the results of the reviews to the parents/carers should be carefully coordinated.

    Should a child normally resident in Norfolk die abroad the NSCB will be reliant on any professionals becoming aware of this death to notify the CDOP administrator. Decisions will be reached on a case by case basis by the designated doctor for child deaths or designated professional as to how the reviews for these children should proceed. Relevant professionals should make efforts through the normal channels to obtain information from foreign authorities as to the circumstances of the death and feedback to the rapid response/child death review process via the CDOP administrator.

    In the case of the death of a looked after child, the LSCB for the area of the local authority looking after the child should exercise lead responsibility for conducting the child death review, involving other LSCBs with an interest or whose local agencies have had involvement as appropriate.

    4.5. Consideration of transplanting organs

    In cases where a child’s death is within a hospital and is controlled (i.e. imminent death is expected following the withdrawal of life sustaining treatment such as mechanical ventilation), organ donation should be considered. Organ donation is possible in children following a controlled circulatory death and in those certified dead using neurological criteria (i.e. completion of brain stem death tests). This includes all children from 37 weeks corrected gestational age.

    Limited organ and tissue donation may also be possible in unexpected and expected deaths, after cardio-vascular death. Senior paediatric professionals involved should consider discussing this possibility and arranging a meeting for the family with the organ donation team.

    Referral is made via a 24 hour pager (07659117499) to the on call Specialist Nurse – Organ Donation (SNOD). The SNOD will assess suitability, approach the family if appropriate and coordinate the donation process. Refer to NICE Guideline 135 organ donation for transplantation: improving donor identification and consent rates for deceased organ donation, and local hospital organ donation trust policies.

    5. Notifications

    5.1. Notifying the HM coroner

  • During working hours contact with the coroner can be made via 01603 276493 or by email: norfolk@coroner.norfolk.gov.uk
  • Out of hours contact Norfolk Constabulary on 101

    5.2. Notifying the CDOP administrator

    Any professional who becomes aware of a death of a child should notify the CDOP administrator via telephone (01603 223380) and complete a notification using the following link: https://www.ecdop.co.uk/NorfolkSuffolk/Live/Public within 48 hours. Notification will usually be done by the consultant paediatrician, rapid response health team or hospital safeguarding team.

    5.3. Notifying the acute trust safeguarding team

    The hospital safeguarding team of the acute hospital should be notified by hospital staff when the child is admitted to A&E or as soon as possible if the next working day if admitted out of hours. The hospital safeguarding team should notify the designated safeguarding children team of all child deaths. The hospital safeguarding team will make contact with other allied professionals who have been involved with the child before and after their death to inform them of the child death and gather information. This should include if relevant:

  • Rapid response health team
  • ambulance personnel
  • coroner’s officers
  • child health information department (CHIS)
  • GPs
  • Healthy Child Programme
  • midwives
  • mental health professionals
  • EACH
  • nurses
  • other physicians and surgeons
  • social workers
  • probation officers
  • police officers
  • education settings
  • critical incident team (education)
  • early years workers
  • youth offending team officers

    5.4 Databases and Record Systems

    Professionals receiving the notification should ensure databases and record systems are updated to record the child as deceased. Health professionals must notify the child health information department (CHIS) on 0300 303 2676. All steps should be taken to ensure that communications and mailings such as appointment letters are not sent out for children who have died.

    On receiving the information of a child death, health care staff (GP surgeries, Healthy Child Programme, other community health care professionals) should liaise and coordinate on-going provision of bereavement support to the family.

6. Appendices

Appendix 1 – Child Death Flow Chart Unexpected Death
Appendix 2 – Child Death Flow Chart Expected Deaths
Appendix 3 – Acute hospital policy for management of SUDIC
Appendix 4 – Managing Child Death Policy Contact Numbers
Appendix 5 – Overview of professional roles and responsibilities
Appendix 6 – NSCB child death leaflet for families


HM Government (2017) Child Death Review Statutory Guidance. London.

HM Government (2018) Working Together to Safeguard Children. London.

National Institute for Health and Care Excellence (NICE) (2016) Organ donation for transplantation: improving donor identification and consent rates for deceased organ donation. NICE. London.

Parliament (1989) Children Act. The Stationary Office. London.

Parliament (2004) Children Act. The Stationary Office. London

Parliament (2007) Mental Health Act. The Stationary Office. London.

Royal College Pathologists and Royal College of paediatrics and child health (2016) Sudden Unexpected death in infancy and childhood: Multi-agency guidelines for care and investigation. London.

The Society and College of Radiographers and The Royal College of Radiologists (2017) Radiological investigation of suspected physical abuse in children. London.

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