CHAPTER 29: Rapid Response to the Unexpected Death of a Child

Appendix 1 and 2 have been added to this chapter in September 2009

Introduction
Scope
Principles
General Advice for All Staff
Initial Action
Initial Multi-Agency Communication
Visit to Place of Death or Collapse
Further Multi-Agency Discussion
Post Mortem
Case Discussion Following Preliminary Results of Post Mortem
Final Case Discussion Meeting
Further Guidance

Appendix 1: Rapid Response Flowchart for Berkshire East

Appendix 2: Rapid Response Flowchart for Berkshire West

1. INTRODUCTION

1.1	Regulation 6 of the LSCB Regulations 2006 (SI 2006 No. 90) implements the duty to provide a co-ordinated response by the local authority and its board partners and other relevant persons to an unexpected death of a child. This came into effect on 1 April 08.

2. SCOPE

2.1	A co-ordinated response into unexpected child deaths has twin goals of investigation of the circumstance in order to understand why the children died and to provide support to the bereaved.
2.2	An unexpected death is defined as the death of a child that was not anticipated as a significant possibility 24 hours before the death, or where there was a similarly unexpected collapse leading to or precipitating the events that led to the death. The designated paediatrician responsible for unexpected deaths in childhood should be consulted where professionals are uncertain about whether the death is unexpected. If in doubt, these procedures should be followed until the available evidence enables a different decision to be made.
2.3	This procedure applies to all unexpected child deaths whether explained or not, although the level of response will be determined by the facts of the case.
2.4	The circumstances surrounding unexpected deaths vary greatly and services must offer a proportionate response. A child who dies in a plane crash will require a different response to one who dies as a result of abuse and one who dies from a previously undiagnosed medical condition a different one still. Unexplained deaths will require greater investigation input than the child who dies suddenly of known causes.
2.5	Each death is an individual tragedy, and it must be remembered that the all families whether the child dies from known or unknown causes will require support through the process.
2.6	This procedure applies whether the child was in the care of a parent, hospital ward, foster carer, children's home, boarding school, child minder, day care provider, hospital or any other carer.

3. PRINCIPLES

3.1

When dealing with an unexpected death of a child of any age, the following principles must be maintained:

Sensitivity, open mind and balanced approach
Recognition of cultural needs
An multi-agency approach involving working together and sharing of information
Proportionate and appropriate response to the circumstances
Preservation of evidence
Good record keeping
Congruence with specific requirements of local coroner
Fast response and the need to conclude any enquiries or investigations expeditiously so the funeral is not delayed unnecessarily

3.2

Police attendance should be kept to the minimum required and officers must be sensitive to the distress caused by uniforms, marked police cars, personal radios and mobile phones.

4. GENERAL ADVICE FOR ALL STAFF

4.1

This is a very difficult time for everyone and though the time spent with the family may be brief, it could influence how relatives deal with the bereavement for a long time afterwards. The following points should be remembered:

The family are in the first stages of grief and may be shocked, numb, withdrawn or hysterical
It is helpful to compile a verbatim and detailed initial account of events, including timings
It is normal for a parent to want physical contact with her/his dead child and this should be allowed, albeit observed, except in exceptional circumstances to preserve evidence
The child should be handled as if s/he were still alive and her/his name used at all times
The impact of religious / cultural beliefs on parent/s responses
The need to allow time for parents to ask questions, including where their child will be taken and when they are able to see her/him again
Provision of written contact details to parents
The possibility that there will be an inquest by a coroner to establish the circumstances of death
The need for agency professionals to ensure they keep written records of the referral and subsequent contact

5. INITIAL ACTION

5.1	The provision of medical assistance to the child is the first priority and an ambulance requested, unless already in attendance.
AMBULANCE STAFF & GPS
5.2	Generally the ambulance service (or GP if first professional on the scene) should not assume death and thus should: Try to resuscitate immediately (unless clearly inappropriate) and then If police are not already present, notify them and consult if the child's body should be immediately transported to A & E - babies should always be taken to A & E and older children will usually be, unless the circumstances of death require the body to remain at the scene for forensic examination Arrange for the deceased child to go to A & E or children's hospital by ambulance (or, if police decide it is not appropriate to move the body, the doctor confirming death must inform the designated paediatrician with responsibility for unexpected deaths in childhood) Prior to arrival, provide relevant information and history to A & E
5.3	Where the child has clearly been dead for some time, attempted resuscitation may be inappropriate and a forensic medical examiner (FME) or GP may certificate the fact of death at home and inform the police (via the police control room) and coroner's office.
5.4	The family should be taken to A & E to ensure receipt of appropriate medical and social support.
5.5	Professionals present should take note of the position of the child, clothing worn and circumstances of how the child was found, living conditions and any comments made by parents / carers.
5.6	Any information (including suspicions) should be passed onto the receiving hospital doctor and directly to the police.
HOSPITAL STAFF
5.7	A & E staff must inform the consultant paediatrician or A & E consultant immediately of the arrival of the child & family and: Attempt resuscitation (unless clearly inappropriate appropriate) according to the UK Resuscitation Guidelines (2005), until the paediatrician on call has decided to stop further efforts Establish identity of those present and their relationship to the child Allocate member of staff to support parents / carers and keep them informed at all times (may be the consultant paediatrician) Check that the police have been notified (via the police control room) if the child is dead on arrival or subsequently dies Undertake checks with Children's Social Care
5.8	The consultant paediatrician on call should undertake the initial examination (the consultant in emergency medicine may also need to be involved and for children over 16 years, may be more appropriate). The paediatrician should undertake a full general examination and: Report on injuries, rashes and observations about the child's physical condition Record site and route of any intervention in resuscitation Establish a detailed and careful history of events leading up to and following the discovery of the child's collapse Obtain a full medical and family history, including siblings, history of other child deaths and medical concerns Inform the police immediately if injuries or concerns noted Ensure personal mementos, clothing or bedding are not removed prior to consultation with coroner and police (there should be a clear audit trail evidencing who has taken property, when and where it can be found) Allow parents to see and hold their child, with discreet supervision, both in the hospital and in the mortuary Speak directly to the coroner's office Take investigative samples as agreed with the pathologist and coroner (NB the site at which post mortem samples are taken must be licensed to do so) Consideration of a full skeletal survey in consultation with the pathologist (this should be undertaken prior to the autopsy as may significantly alter the required investigations)
5.9	When the child is pronounced dead the consultant paediatrician on call must inform the designated paediatrician (or other senior professional if this is agreed locally - this is left unspecified as different hospitals may have different systems; there are some duties in this procedure for the designated paediatrician, which may be undertaken by others, e.g., designated nurse) with responsibility for unexpected deaths in childhood and agree which of them will: Request and review all hospital records of the child and siblings, and arrange for the records to be photocopied for the police Inform the parents of the death and the known medical facts (this should be in the privacy of an interview room, but in the presence of the member of staff allocated to support the family) Explain to parents that the coroner has to be informed to decide if a post mortem will be necessary to try to discover cause of death Explain to parents that the child death overview panel has to be informed to as part of their function to review all child deaths Provide information on the post mortem process, including a leaflet and parents rights to be represented at the post mortem by a medical practitioner of their choice, provided they have notified the coroner (Coroners' Rules 1984) Explain to parents that the police will be involved and Children's Social Care records will be checked as a matter of routine practice and a home visit made Introduce police to parents if police lead investigator already at the hospital Provide information and support e.g. leaflets published by the Foundation for the Study of Infant Deaths
5.10	The comments of parent/carers should be noted in detail.
5.11	Parents / carers should not be left unsupervised with the child's body - staff should maintain a discreet presence.
5.12	Anyone who contributes to the written records must legibly sign, date and put her/his designation / role.
5.13	Where sudden unexpected death is certified outside hospital and transfer to hospital is clearly inappropriate, attending professionals must inform the Designated Nurse as below. If in doubt, pleases discuss with on call paediatrician at WPH.
5.14	If a child or young person has been taken straight to the mortuary (as will often happen with 16 and 17 years who are clearly dead), the coroner's representative, who visits the mortuary daily, will immediately notify the Designated Paediatrician of the death. The Designated Paediatrician will then initiate the Rapid Response process if the death was unexpected.

6. INITIAL MULTI-AGENCY COMMUNICATION

6.1	As soon as possible after the child's arrival at A & E / confirmation of the child's unexpected death the coroner and police must be informed.
6.2	The paediatrician on call / designated paediatrician with responsibility for unexpected deaths in childhood must initiate immediate multi-agency information sharing and planning discussion/s (by telephone and/or meeting) with lead agencies involved i.e.: Coroner's office Police must be contacted and arrangements made for the officer designated to lead the investigation to be introduced to the parents whilst they are at the hospital (if possible) and talk to the parents jointly with the paediatrician at the home visit (see Paragraph 6.9) Children's Social Care (duty) should be contacted (possibly more that 1 authority if the child died away from home) and its records checked: the relevant paediatrician should communicate directly with the duty / allocated social worker if the family are known The child's GP, health visitor and school nurse (if applicable) should be contacted as soon as possible to ensure they are fully informed and to obtain relevant information Any other relevant professionals / agencies should be contacted
6.3	Where the child who has died lives very close to a local authority border or receives services from more than one area, cross boundary issues regarding who is more appropriate to lead the Rapid Response procedures may occur.
6.4	In general, for children aged under five, the Rapid Response process will be led by the Designated Doctor covering the area of GP registration, especially where a home visit would be appropriate. For older children, the process will usually be co-ordinated by the Designated Paediatrician covering the child's area of residence.
6.5	In cases where there is doubt about which area should co-ordinate the Rapid Response, the Designated Doctors (or nominated representatives) will discuss directly and come to a decision.
6.6	Where the death occurred in a hospital, the plan should also address the actions required by the Trust's serious incidents protocol.
6.7	Where the death occurred in a custodial setting, the plan should ensure appropriate liaison with the investigator from the Prisons and Probation Ombudsman.
6.8	For all unexpected deaths (including those not seen in A & E) urgent contact should be made with any other agencies who know or are involved with the child including CAMHS, school, early years services to ensure they are informed and to obtain relevant information on the child, the family and other members of the household.
6.9	If significant concerns are raised at these discussions about the possibility of neglect or abuse, the police should become the 'lead agency' and immediately a formal crime scene investigation at the site of the child's collapse or death. In all other cases Health, led by the paediatrician will remain the lead agency.
6.10	At this point the normal multi-agency child protection procedures will apply and a Section 47 Enquiry will be initiated about any surviving siblings if appropriate.
6.11	If initial discussions reveal the cause of death is unknown and it appears a crime has not been committed agencies will need to consider the support needs of the family, and should identify a professional who will take responsibility for meeting these.

7. VISIT TO PLACE OF DEATH OR COLLAPSE

7.1	At the discretion of the senior investigating officer, the police may have visited the scene of death immediately, and before discussion with the parents.
7.2	The senior investigating officer and senior health care professional should make a decision about whether to visit the place the child died or collapsed, if this occurred outside of the hospital. For infants who die unexpectedly this should almost always occur (see Paragraph. 5.1 in Sudden Unexpected Death in Infancy The Royal College of Pathologists and The Royal College of Paediatrics and Child Health, September 2004.
7.3	Within 24 hours of the death, the designated paediatrician for unexpected child deaths (or alternative senior health professional experienced in responding to unexpected child deaths) and senior police investigating officer should consider whether it is appropriate to undertake a joint home visit (or to the place where the child collapsed / died if different) to: Explore the circumstances of the death, relevant events and previous history Carry out a systematic examination of the site of the child's death
7.4	If a joint visit is impossible within this time frame, separate visits should occur.
7.5	The family's GP and health visitor could usefully be included in this meeting and should ensure arrangements are quickly put into place for appropriate bereavement support.
7.6	The Coroner's Office should be informed of the visit and information provided to parents about Coroner's procedures.
7.7	It must be explained to parents that this is a routine part of the investigation to help identify and understand the factors that have contributed to the death and contribute information for the pathologist, prior to the post mortem examination.
7.8	Arrangements should be made to ensure that the scene of the child's collapse and / or death is left undisturbed until the visit takes place.

8. FURTHER MULTI-AGENCY DISCUSSION

8.1	Following this visit to the scene of the collapse / death, the designated paediatrician for unexpected child deaths, senior investigating police officer, health visitor and GP and any other involved professional should review the findings.
8.2	If concerns about the possibility of abuse or neglect have been newly identified, Children's Social Care should initiate Strategy Discussions, and Section 47 Enquiries as appropriate on any surviving siblings and the police should (if not already initiated) institute a 'crime scene investigation'. The LSCB should consider the appropriateness or not of holding a Serious Case Review.
8.3	Strategy discussions or meetings under child protection procedures can take place at the same time as discussions concerning the rapid response to an unexpected death, but care must be taken to ensure that enquiries about concern of abuse or neglect of surviving children are conducted in line with Section 47 Enquiries Procedure. The two processes must be recorded separately.

9. POST MORTEM

9.1	The post mortem examination will be ordered by the coroner, and should be carried out as soon as possible by the most appropriate pathologist available (this may be a paediatric and/or a forensic pathologist) who will perform the examination according to the guidelines and protocols laid down by The Royal College of Pathologists.
9.2	The designated paediatrician for unexpected child deaths should fully brief the pathologist/s by presenting the collated information collected by those involved in responding to the child's death.
9.3	The post mortem should routinely involve a full radiological skeletal survey, reported on by a radiologist with paediatric training and experience.
9.4	Where the death is deemed to be unnatural or the cause not yet determined, the coroner will hold an inquest.
9.5	The paediatrician's report to the coroner should review all relevant medical, social and education records, clinical circumstances of the death and the history obtained at the home visit. This report should be delivered to the coroner within 28 days of the death, unless some critical information is not yet available.

10. CASE DISCUSSION FOLLOWING PRELIMINARY RESULTS OF POST MORTEM

10.1	The preliminary results of the post mortem belong to the commissioning coroner. The pathologist should discuss these, as soon as possible, with the designated paediatrician and senior investigating police officer and the coroner immediately informed of the initial results.
10.2	If the post mortem findings suggest evidence of neglect or abuse: The police will become the lead investigating agency and provisions of normal criminal investigations set into motion Children's Social Care must be informed and take immediate responsibility for initiating a Section 47 Enquiry for any surviving siblings, in accordance with Section 47 Enquiries Procedure Consideration should be given to the appropriateness or not of holding a Serious Case Review
10.3	If this is not the case, the designated paediatrician for unexpected child deaths should communicate the findings to the primary care team and the family, although the police may wish to be involved in the process.
10.4	In all cases there should be a further multi-agency discussion (usually on the telephone) involving pathologist, Coroner's officer, police, Children's Social Care, the designated paediatrician for unexpected child deaths and other relevant healthcare professionals to discuss the post mortem findings and ensure no additional information has emerged relevant to safeguarding issues. This should occur within 5-7 days after the death.

11. FINAL CASE DISCUSSION MEETING

11.1	The designated paediatrician for unexpected child deaths should convene and chair a case discussion meeting as soon as possible after the final post mortem result is available (the timing will vary according to circumstances, but should be no more than 8 - 12 weeks after the death).
11.2	The meeting, usually in the health centre / GP surgery, should include professionals who knew the child and family and those involved in investigating the death i.e. GP, health visitor / school nurse, paediatrician/s, pathologists, senior police investigating officer and where appropriate Children's Social Care. The coroner or coroner's officer will be involved and may choose to attend the meeting, or may agree to the police attending as both the investigating agency and the coroner's representative.
11.3	At this stage the collection of core data should be completed and, if necessary, previous information corrected in a manner consistent with enabling the change to be audited.
11.4	The purpose of the meeting is to: Share and review information Agree a formal classification of the cause of death (this will always be subject to revision at any inquest) Identify factors that contributed to the death Explicitly comment on the presence or not of concerns about abuse and neglect causing or contributing to the death - if no evidence of maltreatment this should be clearly documented Explicitly comment on the quality of medical and social care and consider potential lessons to be learnt Agree how detailed information about cause of death will be shared with the parent, by whom and who will offer ongoing support
11.5	Families are not ordinarily invited to the meetings, but should be fully informed of the outcome at the earliest opportunity, usually at a meeting with the designated paediatrician for unexpected child deaths or the paediatrician responsible for the child's care and a member of the primary health care team. The parents should also be provided with written information on the outcome.
11.6	Where abuse is suspected and/or the police are conducting a criminal investigation, the paediatrician should discuss with police and Children's Social Care what information should be shared, how and when.
11.7	The designated paediatrician for unexpected child deaths is responsible for providing an agreed record of the meeting and all reports to the coroner The coroner will take this into consideration in the conduct of the inquest and in cause of death notified to the Registrar of Births and Deaths.
11.8	The summary of the case discussions and the record of the core data set should be made available to the Child Death Overview Panel when the child dies away from their residential area.

12. FURTHER GUIDANCE

12.1	The Foundation for the Study of Infant Deaths produces a range of leaflets and information for families and professionals (tel: 020 7235 1721). See also Sudden Unexpected Death in Infancy The Royal College of Pathologists and The Royal College of Paediatrics and Child Health, September 2004

Appendix 1: Rapid Response Flowchart for Berkshire East

Click here to view Berkshire East Flowchart

Appendix 2: Rapid Response Flowchart for Berkshire West

Click here to view Berkshire West Flowchart

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