Procedure for Rapid Response to an Unexpected Child Death

This procedure is intended for anyone involved in the response to an unexpected death of a child.

1. Introduction

Local Safeguarding Children Boards are required, through Regulation 6 of the Children Act 2004, to put in place procedures for ensuring that there is a coordinated response by the Local Authority, their Board partners and other relevant persons to an unexpected death of any child normally resident in their area.

2. The Aim of the Rapid Response Process

  • To make immediate enquiries into and preliminary evaluation of the reasons for and circumstances of the death.
  • To explicitly consider whether there are any safeguarding issues for surviving siblings, potential future siblings and other associated children.
  • To identify any urgent action to be taken by any agency.
  • To signpost to appropriate help and support for family/friends and staff where necessary.
  • To help gather information for Tees Child Death Overview Panel (CDOP) in a standard format.

Each unexpected death of a child is a tragedy for the family and subsequent enquiries/investigations should keep an appropriate balance between forensic and medical requirements and the family’s need for supportChildren with a known disability or a medical condition should be responded to in the same manner as other children.

A minority of unexpected deaths are the consequence of abuse or neglect, or are found to have abuse or neglect as an associated factor. In all cases, enquiries should seek to understand the reasons for the child’s death, identify possible needs of other children in the household, the needs of all family members and also consider any lessons to be learnt about how best to safeguard and promote children’s welfare in the future.

The Rapid Response Process may also identify cases which require consideration for a Serious Case Review or Learning Review.

3. Which deaths are covered by the Rapid Response Process?

An unexpected death is defined as the death of a child, in any setting, 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.

Child deaths for which a Rapid Response is likely or certain to be appropriate:

  • Cardio-respiratory collapse of a previously healthy child of any age, including Sudden Unexpected Deaths in Infancy
  • Where self-harm seems likely
  • Death from any lethal injury such as falls, drowning, fire, etc.
  • Death that appears to be from a disease that is rarely lethal, such as diabetes or asthma
  • Deaths occurring in hospital (usually in intensive care) that follow any of the above.
  • Deaths where the immediate cause of death is unclear
  • Deaths where criminal acts are suspected.

Child deaths for which a Rapid Response is very unlikely to be appropriate:

  • Deaths of babies occurring in hospital either shortly after delivery, or in infants so seriously unwell that they have never left hospital since birth
  • Infants and children dying in hospital of a diagnosed disease, even when the onset is very rapid
  • Children dying while in receipt of an organised palliative care programme, either through a hospice, Macmillan nurses, or some other clinical team
  • Most deaths in children with degenerative, neurological, metabolic or other severely life-limiting illnesses, regardless of the place of death.

The Rapid Response Process covers all unexpected child deaths up to their 18th birthday.

4. Process (see flow chart below)

Download a copy of the flowchart here.

5. Notification of an Unexpected Death 

The Designated Doctor for Child Deaths and the administrator for the Rapid Response Process should be informed as soon as possible after an unexpected death of a child. Tel No: (01642) 745028 e-mail: NECSU.TeesChildDeaths@nhs.net 

If the child is known to have a Social Worker they should also be notified as soon as possible.

The main routes by which notification is received are via Accident & Emergency, the Acute Paediatric Team, Cleveland Police and Ambulance service.

Other routes of notification include Paediatric Intensive Care Unit, the coroner’s office/police coroners officer or by the pathologists.

6. Phase 1 meeting (within 24-48 hours of the child’s death)

Designated Doctor for Child Deaths will advise the Rapid Response administrator regarding appropriate professionals to invite to the meeting.

The Rapid Response Administrator will notify the single point of contact (SPOC) within the relevant agencies involved with the child, request they review information held by the agency regarding the child/family and invite them to the initial meeting.

Suggested list of relevant invitees:

  • North East Ambulance Service (calls to be listened to prior to the meeting)
  • Health Visitor
  • School Nurse
  • Midwife
  • Mental Health Professional
  • Police
  • Pathologist
  • GP
  • School
  • A & E staff
  • Paediatrician
  • Children’s Services (Local Authority)
  • Designated Nurse
  • Designated Doctor for Child Deaths
  • Drug and Alcohol Services
  • Community Paediatric Nurse (where appropriate)
  • National Probation Service (NPS)
  • Community Rehabilitation Company (CRC)

Reports should be submitted if practitioners are unable to attend.

Remit/Function of the Phase 1 meeting:

  • For each agency to share relevant information from previous knowledge of the child and family. In particular any reference to the circumstances of the child's death, previous or ongoing child protection concerns, known risk taking behaviours, previous unexplained or unusual death in the family.
  • Relevant information may also be shared about family members and others involved with such as parental substance misuse, mental health issues and domestic abuse.
  • To collate all relevant information to share with the pathologist.
  • To plan any subsequent enquiries, including the means for reviewing actions and in meeting identifiable timescales.
  • To enable consideration of any child protection risks to siblings/any other children living in the household and to consider the need for child protection procedures in relation to surviving children.
  • To consider the need for any other action e.g. health review for any other child in the family;
  • To ensure appropriate support is provided to the family, including a co-ordinated bereavement care plan.
  • Plan best person to liaise with the family.
  • To consider staff welfare and support.
  • To refer to the relevant Local Safeguarding Children Boards Learning and Improvement Sub Group in order for consideration to be given regarding if the criteria for SCR/Learning Review has been met, providing detailed rationale as to the reason for the referral.
  • Ensure co-ordination with any parallel processes - criminal investigation, serious patient safety incidents and investigation of deaths in custody.
  • Agree a mechanism for managing any potential media interest ensuring the relevant LSCB is notified. Clear distinction should be made as to which agencies will be responsible for any media enquiries. CDOP would not be involved in any media response. 
  • To consider if future meetings are necessary.
  • Should any safeguarding concerns arise consideration should be given to holding a further meeting.

NB. Where a criminal investigation is underway, all those present should be advised that a record of the meeting will be made and may subsequently be used in criminal proceedings.

7. Phase II – Local Case Discussion

The Designated Paediatrician for Child Deaths will convene and chair a further case discussion following the final results of the post mortem examination becoming available. This will always take the form of a meeting. The Police and a Consultant Paediatrician should always attend, in addition to other professionals involved with the family in the initial case discussion.

The purpose of the meeting is to share information to identify the cause of death and/or those factors that may have contributed to the death and then to plan the future care for the family. Potential lessons to be learned may also be identified at this stage. The outcome of this meeting will inform any Inquest that takes place.

The meeting should explicitly address the possibility of abuse or neglect as causes or contributory factors in the death, and the outcomes of this should be recorded.

The meeting should agree on how the parents will be informed about the outcome of the meeting and how they will be provided with on-going support.

The Consultant Paediatrician, at the earliest opportunity, should arrange to inform the parents of the outcome of the post mortem. This sharing should be consistent with the requirements of the Coroner and Police Enquiries.

A report outlining the meetings held and findings of information sharing should be forwarded to the Child Death Review Co-ordinator / Administrator.

If no evidence is identified to suggest neglect or abuse as contributory factors, this should be documented as part of the report of this meeting. The quality of medical and social care that was given to the child and family should also be discussed at this meeting, identifying any shortcomings and appropriate measures to improve future care. For these reasons, holding such a meeting, even in those instances in which a complete and sufficient medical (natural) explanation has been found for the death, may be of value.

8. Out of Area Deaths

The area in which the death of a child has been declared must take the initial responsibility for convening and co-ordinating the rapid response process until agreement for handover can be secured within the area where the child is normally resident.