11.1 Managing Child Deaths

The following policy outlines the local procedures for the implementation of processes outlined in Regulation 6 of the Local Safeguarding Children Board Regulations 2005, Chapter 5 of Working Together to Safeguard Children 2018 and Child Death Review Operational Guidance (England) October 2018.

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

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

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

This chapter was revised and updated in August 2020.

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. It includes children who normally reside in Norfolk, 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 (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 the Child Death Review Partners and other 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:

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 Child Death Review Process;
  • To preserve evidence;
  • To identify and share 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.

1.3.1. Unexpected death – Pathway One – see flowchart below

This would include:

  • 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.

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.

1.3.2. 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.

Management of all Unexpected Deaths in Infancy and Childhood (0-17 years)

1.4. Initial response to an unexpected child death at home (other)

  • 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 (see below*) and the child should be transferred to an emergency department prior to their death being declared.

  • *Where resuscitation is clearly inappropriate, the death can be declared at the scene by an appropriately qualified professional but the child 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 Child Death Review 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 child’s body must remain at the scene for forensic examination; or
    • there is significant trauma to the child’s 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.

1.5 Deaths due to Road Traffic Collisions

The child’s body should be transported to the emergency department (as per all unexpected deaths) unless the Senior Road Traffic Officer considers the trauma is such that it would be inappropriate under these circumstances. If they are taken directly to the mortuary, the joint agency response must be triggered, and the Senior Road Traffic Officer should inform the Child Death Review Team of the child’s death. If there are life threatening injuries but the child does not die at the scene the senior investigating officer should consider triggering a joint agency response and discuss the case with the Child Death Review team.

1.6. Unexpected child death in a 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). The Child Death Review team must be contacted and the death will be subject to a joint agency rapid response.

Areas of the hospital who admit adolescents aged 16–up to their 18th birthday must be aware of the Child Death Review processes, A&E and adult ITU in particular.

1.7. Initial assessment on arrival A&E

The joint agency response should also be triggered if a child is brought to hospital near death and is successfully resuscitated but expected to die in the following days. This includes from a road traffic accident. A joint agency response should be considered at the point of presentation rather than death as this enables an accurate history of events to be taken.

1.7.1. 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). This is standardised guidance across the three Norfolk acute hospital trusts.

1.7.2. Kennedy samples

  • As soon as possible after the death (or if child is in extremis), Kennedy sampling should be taken in accordance with the acute hospital SUDIC policy.
  • Covid swabs to be taken at time of Kennedy sampling for all unexpected child deaths.
  • 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 consider SUDIC sampling for children who are expected to die, because of their collapse to help identify a cause because the opportunity maybe lost later (e.g. toxicology).
  • 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.
  • 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.

1.7.3. 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), a discussion with the coroner and the radiology department should take place to  consider undertaking the survey on-site within working hours.

1.7.4. 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. Photographs should be taken and stored, and consent obtained in accordance with agreed hospital trust and police procedures.

1.7.5. 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. The reasons why they have not been cleaned should be explained.

1.7.6. Immediate information sharing and planning discussion (within 2 hours of death)

  • An immediate 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 discussion should include the senior consultant paediatrician, lead police investigator, a representative from children’s services (CADS/EDT) and in working hours the Child Death Review nurse and the hospital safeguarding team and ambulance crew if still present. The lead police investigator should ensure that children’s social care have undertaken background checks prior to this meeting if a social work representative is not available.

1.8  Purpose of the meeting

  • To get background information from:
    • Social care to underpin further planning and investigation
    • Information from ambulance crew
  • Decision when to undertake joint police and child death review nurse home visit.
  • To consider the need for a s47 Strategy meeting
  • 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. N.B. Delays in allowing this should only occur in exceptional circumstances if the police are considering conducting a criminal investigation.
  • Police should explain to parents or carers that they will inform children’s social care of the death. This ensures that background checks are done and also 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. This is important due to the impact of social media spreading information.
  • In all circumstances, the school should at least be notified of the child death and where families do not consent to information sharing, the Senior Advisor for Schools should be consulted and a decision on how to proceed agreed with Police and Children’s Social Care. There should be an agreed and clearly recorded record outlining the information to be shared and with whom this information can be shared with.

1.9. 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 death will be reported to the coroner.
  • The future involvement of professionals including the police, children’s social care, the health Child Death Review Team and other professionals who know the family who will be invited to the initial multiagency review or S47strategy meeting (if significant safeguarding concerns) that day or the next working day.
  • Details of relevant support agencies and a copy of the 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 they can refer future questions to a keyworker.
  • A key worker may be identified at this stage if possible or by the next working day in the initial child death/strategy meeting.
  • The family 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.

1.10 Notifications

1.10.1 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

1.10.2 Notifying the CDOP administrator

The notification of child death should be completed using the following link: https://www.ecdop.co.uk/NorfolkSuffolk/Live/Public after the initial discussion and certainly within 48 hours of the child’s death. The notification can be done by anyone with the relevant information, usually be done by the Child Death Review health team or consultant paediatrician or hospital safeguarding team. It is better to have more than one notification. It is important to make the notification even if the reporter does not have all the available information. It will go automatically to the CDOP administrator who will notify to the wider NHS and partner agencies.

This should include if relevant:

  • Child Death Review Team
  • Ambulance personnel
  • Coroner’s officers
  • Child health information department (CHIS)
  • GPs
  • Tertiary consultants who treat the child
  • Healthy Child Programme
  • Midwives
  • Mental health professionals
  • EACH
  • Nurses
  • Other physicians and surgeons
  • Social workers
  • Probation officers
  • Police officers
  • Education settings
  • Safeguarding – Education Quality Assurance & Intervention Service
  • Critical incident team (education)
  • Early years workers
  • Youth offending team officers

1.10.3 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 on the next working day if admitted out of hours. The safeguarding team should be notified all child deaths within the hospital including NICU.

The hospital safeguarding team should notify the designated safeguarding children team of all child deaths.

The hospital safeguarding team will make contact with other health/allied health professionals who have been involved with the child before and after their death to inform them of the child’s death.

1.11 Visit to the scene of the death and home visit

This visit will be undertaken by the police officer and health CDRT within 24 hours, preferably before the formal strategy discussion in order to provide information to that discussion. 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 CDRT 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 or Designated Dr for Child Death should 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.

1.12 Child death Multi-agency meeting (within 1 working day of the child’s death)

Where a death is unexpected, consideration should be given as to whether the multi-agency child death meeting should be convened under Section 47 of the Children Act 1989. This meeting will be chaired by the Children’s Social Care Head of Social Work.

Alternatively, if a Section 47 Strategy meeting is not required, a Child Death multi-agency meeting will be convened, led by the Local Authority. In the future, once resources are identified, this will be led by Health.

The following should be invited:

  • Children’s Social Care
  • Police
  • Ambulance service
  • Lead consultant paediatrician
  • Child Death Review Team
  • Paediatrician or representative if under clinical service (JPH, QEH, NCHC, NSFT, West Suffolk, Ipswich, Suffolk community services, consider tertiary units).
  • Hospital Safeguarding Team
  • Senior Adviser Safeguarding – Education Quality Assurance & Intervention Service
  • The child’s GP
  • Designated safeguarding children’s team (Designated Dr CDR or Designated Dr/ Nurse safeguarding)
  • 0-19 service (Cambridge community service)
  • Any other relevant professionals

On conclusion of this meeting:

1. The family’s key worker should be identified if not already agreed.
2. A decision when the ‘initial meeting’ is held see below.
3. The membership of the initial meeting confirmed
4. Provision of support to bereaved family.
5. Whether there is further information to be sought

1.13 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.
  • 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. It is important that clinicians involved in the case are informed of the PM result.
  • Some results from the PM will become available at a later stage as some investigations can take a number of weeks to complete.

2. Initial Child death review meeting (within 5 working days of the child’s death)

For the majority of unexpected deaths, the hospital safeguarding team will arrange a child death review meeting within a week of the multi-agency meeting. The meeting should be chaired by the lead consultant paediatrician.

  • The meeting is required to consolidate information gathered during the week and review all the information obtained since the child’s death and any new information which may be available from initial post-mortem findings.
  • Relevant professionals involved in the care of the child should be invited identified at the multiagency meeting (Day1), including the Safeguarding – Education Quality Assurance & Intervention Service (NCC)
  • The outcomes of this meeting should be captured in Reporting Form B (using eCDOP), and brief minutes from this meeting should be recorded and sent to the coroner, pathologist, and all agencies involved in the meeting and the CDOP administrator.
  • It should be decided whether a date for the final child death review meeting date can be agreed or whether it is likely to be delayed due to further investigations i.e. forensic coroners PM, serious incident (SI) investigation, Root cause analysis.

2.1 Final 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. This may be delayed if awaiting the outcome of a SI (serious incident) investigation.

  • Prior to the meeting the family’s key worker will have discussed the purpose of the meeting and bring any questions that the family has to the meeting and 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 lead consultant paediatrician or in some circumstances the designated doctor for child death supported by the hospital safeguarding team and the health RRT.
  • Representation will include professionals involved in the care of the child, including children’s social care, police, ambulance, 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, 2018. The meeting will also identify any modifiable/ contributing factors and consider any lessons to be learned.
  • The findings of this meeting should be captured electronically in a draft Analysis Form C using the eCDOP software.
  • 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, usually through the key worker.

2.2 Follow up Bereavement meeting with parents/carers

The consultant paediatrician and or the key worker 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 – see flow chart below

The review of expected deaths now falls under the same statutory guidance as for unexpected deaths.

Management of Expected Deaths in Infancy and Childhood

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

An end of life care planning meeting for end of life care should be convened. This may be a face to face or virtual meeting or part of ongoing series of planned meetings. 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 if appropriate, general practitioner, Child Death Review Team, 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 frequency of on-going end of life care multi-disciplinary meetings will be agreed. 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 or equivalent. This information should be completed on the RESPECT documentation.

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 or GP.

  • 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, the local East Anglia Hospice or other declaring professional is responsible for notifying the death to the CDOP administrator by completing the online notification form using the following link: https://www.ecdop.co.uk/NorfolkSuffolk/Live/Public . 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 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.

3.4. Initial information gathering and sharing meeting (as soon as reasonably possible, guidance suggests the first week)

  • When a child is expected to die there will have been regular multi-disciplinary meetings prior to the death. After the child dies the relevant professionals will be invited to contribute to virtual initial information sharing process debrief ‘’ unless an MDT meeting date coincides with the death. The virtual meeting should be convened by the lead professional (e.g. hospital paediatrician, hospice, GP).
  • If there have been no planned MDTs, then an initial child death review meeting should be arranged as soon as possible to discuss the case as above
  • The purpose of the meeting is to coordinate support to the family, coordinate information sharing, identify who could complete Reporting 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 sent to all agencies involved in the meeting and the completed Reporting Form B should be sent to the CDOP administrator electronically using the eCDOP software.
  • On conclusion of this meeting a final child death review meeting date should be considered.

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

  • The timing will depend on when the MDT had already planned to meet within the 6 to 8 weeks following the death. The lead professional/membership of this meeting agreed and decision re chair. This may be undertaken at either the original referring hospital or tertiary hospital who provided care and ideally coordinated together. The MDT team may decide whether they feel a further meeting is required by them or whether they would join the hospital meeting.
  • The lead paediatrician or palliative clinician for child death will chair this meeting (or rarely the designated doctor).
  • Clear guidance has been provided regarding the purpose and structure of these meetings in accordance with the Child Death Review Statutory and Operational Guidance, 2018. 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. The findings of this meeting should be captured electronically in a draft Analysis Form C using the eCDOP software.

3.6. 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 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 Child Death Review process and CDOP cannot be finalised until these reviews are concluded.

4.2 Safeguarding Practice Reviews (SPR) previously known as Serious Case Reviews

Safeguarding practice reviews are statutory reviews conducted by Local safeguarding children’s partners (LSCPs) 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 SPR.

4.3 Child Death Overview Panel (CDOP)

  • All child deaths are subject to a multi-agency review by the CDOP. The review at CDOP will take place following the completion of all other investigations. 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 practice 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.

4.4. 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 Norfolk CDOP 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 local CDOP manager 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 partnership 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 Partnership 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 CDOPs 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 NSCP 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 child death review process via the CDOP administrator.
  • In the case of the death of a looked after child, the safeguarding partnership for the area of the local authority looking after the child should exercise lead responsibility for conducting the child death review, involving other LSCPs 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 (07659 117499) 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.

4.6 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.
  • The information provided from the completion of Notification (Form A), Reporting (Form B) and Analysis (Form C) will be stored within the eCDOP software and data will be submitted as per statutory requirements to the National Child Mortality database.

5. Appendices

Appendix 1 – Acute hospital policy for management of SUDIC
Appendix 2 – Managing Child Death Policy Contact Numbers
Appendix 3 – Overview of professional roles and responsibilities
Appendix 4 – 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.

< Previous Next >