8.43 Unexpected Child Death

This is the fourth version of the Sussex Joint Agency Protocol for Unexpected Child Deaths, which was originally published in 1999. This latest version takes account of "Sudden Unexpected Death in Infancy" published in September 2004 by the Royal College of Pathologists and the Royal College of Paediatrics and Child Health, and the statutory guidance in Working Together to Safeguard Children, HM Government 2015. These reports contain further detail on this subject and recommendations relating to the investigation of such deaths. These reports can be accessed via Royal College websites: Royal College of Paediatrics and Child Health or The Royal College of Pathologists and Department of Health respectively.

The aim of the protocol is to provide guidance to professionals confronted with the unexpected death of a child. It is acknowledged that each death has unique circumstances and each professional has their own experience and expertise to draw on in their handling of individual cases. There are, however, common aspects to the management of unexpected child deaths and it is important to achieve good practice and a consistent approach.

An unexpected death is one where the death of an infant or child was not anticipated as a significant possibility, for example, 24 hours before the death, or where there was a similarly unexpected collapse or incident leading to or d child precipitating the events that lead to the death.

In dealing with an unexpected collapse it is important to remember that even if a child survives for several days following a collapse before dying from an identifiable cause, a multi-agency response to the death is still required if initial collapse was not anticipated within the previous 24 hours.

The protocol should be applied to all unexpected deaths of children under the age of 18. The protocol will not apply to babies who die under medical supervision having never left the hospital.

When a child with a known life limiting and or life threatening condition dies in a manner or at a time that was not anticipated, the rapid response team should liaise closely and promptly with a member of the medical, palliative or end of life care team who knows the child and family, to jointly determine how best to respond to that child's death. This should include consideration of whether the child's body should be transferred to a hospital or hospice, and whether any investigations or inquiries are required. Where an end of life plan has been agreed by the end of life care team and is in place, this should be followed unless there are pressing reasons not to do so. For example, the coroner decides where the child's body may be taken and this decision may be different to what was set out in the family's prepared plan. The presence of a community children's nurse on call as part of the rapid response team could facilitate the process of communication and fact-finding.

1. Each CCG should ensure that the LSCB, acting through the CDOP, has access to a consultant paediatrician whose designated role is to provide advice on: the commissioning of paediatric services from paediatricians with expertise in undertaking enquiries into unexpected deaths in childhood and the medical investigative services such as radiology, laboratory and histopathology services; and the organisation of such services.
   The designated paediatrician for unexpected deaths in childhood may provide advice to more than one CCG, and is likely to be a member of the local CDOP. This is a separate role to the designated doctor for child protection, but does not necessarily need to be filled by a different person. These responsibilities should be recognised in the job plan agreed between the consultant and his or her employer.
   
   
2. In some areas this role is fulfilled by a Rapid Response/CDOP specialist nurse

The Coroner must be informed at the earliest opportunity of any violent or unnatural death, sudden death of unknown cause, or death within 24 hours of admission to hospital.

Individual cases can always be discussed with a Coroner's Officer or, in an emergency, with the Coroner directly. The Coroner should normally be contacted via the Coroner's Officer.

The Coroner has control of what happens to the child's body in these circumstances and decides which pathologist will complete the post-mortem.

The majority of unexpected child deaths have natural causes and are unavoidable tragedies. The incidence of unexpected child deaths is highest in infancy. About three hundred babies die suddenly and unexpectedly each year in the UK.

Professionals from a number of different agencies and disciplines will become involved following an unexpected child death to enquire into and evaluate the child's death, and where the cause is unknown, to try to establish the cause of the death and support the family.

The type of response to each child's unexpected death will depend to a certain extent on the age of the child and the circumstances of the death; there are clear differences between an infant who dies unexpectedly and a child who dies as a result of a road traffic collision. However, there are key elements that underpin all subsequent work, which are contained in this protocol.

This protocol is intended to provide guidance to the professionals confronted with one of these tragic events.

All professionals need to strike a balance between managing the sensitivities of a bereaved family and identifying and preserving anything that may help to explain why a child has died. A minority of unexpected deaths will be the consequence of abuse or neglect, or be found to have abuse or neglect as an associated factor.  It is as important to identify medical conditions and hereditary disorders, and to absolve a family from blame, as to identify unnatural deaths or homicides.

The protocol contains general guidance about responding to unexpected child deaths and information about individual agency responsibilities. It describes some of the factors that may raise concern about a death.

The key events described in the protocol are:

• Child taken to an A&E Department;
• Immediate information sharing and planning discussion;
• Early investigation;
• Joint home visit;
• Early inter-agency case discussion;
• Paediatric pathology;
• Late multi-agency case discussion.

When dealing with an unexpected child death all agencies need to follow five principles:

• Sensitive, open minded balanced approach;
• Inter-agency response;
• Sharing of information;
• Appropriate response to the particular circumstances;
• Preservation of evidence.

These are of equal importance.

• This is a very difficult time for everyone. The time spent with the family may be brief but events and words used can greatly influence how the family deals with their bereavement in the long term. It is essential to maintain a sympathetic and supportive attitude, whilst objectively and professionally seeking to identify the cause of death;
• Remember that people are in the first stages of grief. They are likely to be shocked and may appear numb, withdrawn, angry or very emotional;
• The child should always be referred to and handled as if he or she were still alive and his or her name used throughout;
• Professionals need to take account of any religious and cultural beliefs that may have an impact on procedures. Such issues must be dealt with sensitively, whilst maintaining a consistent approach to the investigation;
• All professionals must record any history and background information given by parents or carers in detail. Initial accounts about circumstances, including timings, must be recorded verbatim;
• It is normal and appropriate for a parent or carer to want physical contact with his or her dead child. In all but very exceptional circumstances this should be allowed with discreet observation by an appropriate professional;
• Parents/carers should always be allowed time to ask questions and be provided with information about where their child will be taken and when they are likely to be able to see him or her again;
• Parents should always be made aware that Her Majesty's Coroner will be involved and that a post-mortem will be necessary;
• Staff from all agencies need to be aware that on occasions in suspicious circumstances the early arrest of parents or carers may be essential in order to secure and preserve evidence and to conduct the investigation.  Professionals must be prepared to provide statements of evidence promptly in these circumstances.

Click here to view the Summary of professional responsibilities following unexpected child deaths Flowchart.

Immediate Information Sharing and Planning Discussion

When a child dies unexpectedly the police should initiate an immediate information sharing and planning discussion between lead agencies (i.e. health, police and children's social care) to decide what should happen next and who will do what. This should take place as soon as possible after a child’s death and ideally always within 24 hours.

Where a child is initially taken to a hospital other than the local hospital for the area where they reside, the relevant paediatrician at the receiving hospital should be involved in the discussion. Following the discussion, the paediatrician at the hospital should then contact the appropriate paediatrician in the area where the child lives to arrange the transfer of the investigation and share information.

Areas to be addressed include:

• Agreeing whether there is a need for a joint home visit;
• Involving the Coroner;
• Ensuring that any agencies involved with the child (CAMHS, school or early years) are advised of the death;
• To enable consideration of any child protection risks to siblings or other children in the household and referral under child protection procedures;
• Calling the early strategy discussion (after initial PM result is known);
• Triggering any Trusts' Serious Incidents Protocol or where the death took place in a custodial setting, liaising with the investigator from the Prisons and Probation Ombudsman;
• Providing support for bereaved family;
• Gaining consent early from the family for the examination of their medical notes.

Following the unexpected death of a young child all families should be visited at home within 24-48 hours by a police officer responsible for investigating the child's death and a consultant paediatrician or other health professional experienced in responding to unexpected child deaths. The police are responsible for arranging this visit with the duty consultant paediatrician or other health professional.

This joint visit may also be appropriate following the unexpected death of an older child.

Aims:

• To complete and jointly review the medical history at an early stage so as to   identify any possible medical or child protection factors contributing to the death and inform the Coroner and pathologist;
• To provide the family with immediate and later information and advice about medical questions and bereavement support.

A multi-agency case discussion will be convened by children's social care after the initial post-mortem results are known to share information relevant to the investigation of the death, and plan support of the parents. The police officer responsible for investigating the child's death or their representative must be present at this meeting.

The purpose of this discussion is:

• For each agency to review and share information in current or previous case notes or other records which may shed light on the circumstances leading up to the child's death. This includes: medical and family history to help identify possible underlying medical conditions; child protection issues, previous unexplained or unusual child deaths in the family, parental substance misuse, violence, neglect etc, and the initial PM findings;
• To ensure a co-ordinated bereavement care plan for the family;
• To decide whether there is any indication of factors that suggest a need for a serious case review and if so agree the process for requesting a serious case review panel;
• To collate basic information for the CDOP process.

Contributors must include:

• Health - Information from the doctor who declared the death, family health visitor, GP, duty consultant paediatrician or their representative, designated doctor or their representative, the A&E department, and Ambulance Service, school nurse;
• Children's social care; either the duty team or if known the team with involvement;
• Safeguarding Investigations Unit;
• Information from:
• School/education representatives - designated teacher, education welfare officer;
• CAMHS;
• Any other professional with direct involvement with the child.

The designated doctor and nurse should be invited to every discussion. Relevant information will need to be shared with the pathologist(s) and Coroner.

An agreed record of the Early Case Discussion must be sent to the Coroner.

As soon as the final post-mortem result is available a further multi-agency case discussion should then be organised by children's social care, ideally at the GP's surgery. This should include the health visitor, police, GP, paediatrician, coroner's officer and relevant representatives from other agencies. The meeting should be chaired by the paediatrician.

Aims:

• To review the circumstances of the child's death and to share the outcome of the investigation;
• To ensure that no information has been overlooked;
• To decide how detailed information about the cause of death will be shared, and by whom, with the parents;
• To make plans for any future additional care and support that might be appropriate for the family and ensure these are discussed with the family;
• To review the effectiveness of the professionals response;
• Complete collation of core data for the CDOP and forward to the coordinator.

At this meeting all the relevant information concerning the death, the child's history, family history and subsequent investigation should be reviewed.

During the course of the meeting there should be an explicit discussion of whether abuse or neglect could have been a contributory factor to the child's death, and any decisions recorded. This should include whether there is any indication of factors that suggest a need for a serious case review, and if so agree the process for requesting a serious case review panel.

An agreed record of the case discussion meeting should be sent to the Coroner.

Some factors in the history or examination of the child may give rise to concern about the circumstances surrounding the death.  If any of these are identified it is important that the information is documented and shared with senior colleagues and relevant professionals in other key agencies involved in the investigation. The following list is not exhaustive and is intended only as a guide.

Previous child deaths in the family

Two or more unexplained child deaths occurring within the same family is unusual and should raise questions both about an underlying medical or genetic condition as well as possible unnatural events.

Unexplained injury

Unexplained bruising, burns, bite marks on the dead child or a previous history of these injuries should cause serious concern. A child may have no external evidence of trauma but have serious internal injuries.

Neglect

Observations about the condition of the accommodation, cleanliness, adequacy of clothing, bedding and the temperature of the environment in which the child is found are important. A history of previous concerns about neglect may be relevant.

Previous child protection concerns within the family

Inconsistent information

The account given by the parents or carers of the circumstances of the child's death should be documented verbatim. Inconsistencies in the story given on different occasions or to different professionals should raise suspicion, although it is important to be aware that inconsistencies may occur as a result of the shock and trauma of the death.

Inappropriate delay in seeking help

Evidence of drug, alcohol or substance misuse particularly if the parents are  intoxicated or sedated at the time if the death.

Evidence of parental mental health problems or learning disabilities

Domestic Abuse

History or evidence of domestic abuse.

Presence of blood

The presence of blood must be carefully noted and recorded. A pinkish frothy residue around the nose or mouth may be found in some children whose deaths are due to Sudden Infant Death Syndrome. Fresh blood from the nose or mouth is uncommon, and should lead to the consideration of possible maltreatment.

Police

Introduction

It is important for police officers to remember that most unexpected child deaths have natural causes. Police actions therefore need to be a careful balance between consideration for the bereaved family, and the possibility that a crime has been committed.

In cases where the death does not appear suspicious but is unexplained, the Safeguarding Investigations Unit should be involved at the earliest opportunity and assume responsibility for the investigation.

In cases where the cause is death is apparent, as in a road traffic collision, or is homicide or suspected homicide, the investigation will be undertaken by the most appropriate department for the presenting circumstances of the death. However, the local Safeguarding Investigations Unit detective sergeant must be informed of the circumstances of the death at the earliest opportunity in order that they can initiate the multi-agency response contained in this protocol.

Who should attend?

Police attendance should be kept to the minimum required. Several police officers arriving at the house can be distressing, especially if they are uniformed officers in marked police cars. Whenever possible consideration should be given to the initial response being from plain clothed specialist officers, but this may not be possible if a speedy response is necessary. Officers maintaining the integrity of any scene should use unmarked cars where possible.

Initial action at the scene

The provision of medical assistance to the child is obviously the first priority. If an ambulance is not present ensure one is called immediately, and consider attempting to revive the child unless it is absolutely clear that the child has been dead for some time. Ensure that the Detective Inspector (DI)/Detective Sergeant (DS) is informed of any resuscitation attempts in order that they can inform the pathologist.

The first officer at the scene must make a visual check of the child and his/her surroundings, noting any obvious signs of injury. Handle the child as if he or she were alive; ascertain and use the child's name whenever referring to the child.

Normally the first officer attending the scene will be responding to an emergency call relating to a child's death. This officer will assume control of the situation and ensure that the appropriate following specialist officers are contacted and attend:

• A detective inspector (DI) must attend the scene. This will preferably be a Safeguarding Investigation Unit DI. This will not apply in incidents where the death is as a result of a road traffic collision (RTC). In these cases the SIO arrangements for the investigation of RTCs will apply.
• The DI attending the scene of the death will:
  • Assess and appropriately preserve the scene;
  • Decide what level of investigation is necessary;
  • Discuss the circumstances with the duty senior investigating officer (SIO). If the death is thought to be suspicious the SIO must be contacted immediately;
  • Consider the need for seizure of exhibits and any photography/video recording;
  • Discuss with the Coroner's officer/Coroner and paediatrician of the need to undertake a skeletal survey prior to the PM, and if authorised arrange in consultation with the consultant paediatrician. Arrangements will vary between Coroner's areas (see Skeletal Survey);
  • Confirm with the Ambulance Service that the child will be taken to an A&E department *(see Away from the scene);
  • Where the death is initially unexplained, ensure the child is examined at the hospital by a consultant paediatrician;
  • Ensure the attendance of an appropriate police officer at the PM to fully brief the pathologist.
• A detective sergeant, or if unavailable, a detective constable from the relevant Safeguarding Investigations Unit should attend. When Safeguarding Investigations Unit officers are not un duty a CID DS or DC should attend the scene but hand over any enquiries to the Safeguarding Investigations Unit at the earliest opportunity. They will:
  • Act as a source of advice on child protection matters to the DI;
  • Consider any apparent child protection issues at the scene;
  • Consider the needs of any siblings;
  • Undertake enquiries at the direction of the DI;
  • Discuss and if appropriate arrange a joint home visit with a consultant paediatrician or designated rapid response nurse;
  • Inform the Coroner's Officer (see below);
  • Initiate immediate information sharing and planning discussion (seeInter-Agency Working, Immediate Information Sharing and Planning Discussion);
  • Notify circumstances of the death to HQ CID;
  • Ensure in liaison with the paediatrician that all medical records and a copy of the pathologists enquiry form are made available at the PM;
  • Request and retain the relevant personal child health record form the parents and provide copies to health professionals when requested;
  • Ensure parents are aware of available support organisations and that the following are given to them.

Guide to the post-mortem examination: brief notes for parents and families who have lost a baby in pregnancy or early infancy - DoH

When a baby dies suddenly and unexpectedly - The Lullaby Trust

Memory Folder - Child Bereavement Trust

• A Coroner's Officer from the relevant Coroner's Office will attend in most areas of Sussex. (However, there are still some areas where this does not happen.) They will:
  • Liaise with the DI/DS at the scene;
  • Liaise with the Coroner;
  • Discuss the need for skeletal survey with the DI/DS (see Skeletal Survey);
  • Consult the paediatrician re marks and injuries;
  • Advise re authority to take samples (see medical investigations in hospital section);
  • Ensure all forms are completed and are available for them to forward to the paediatric pathologist;
  • Advise re planned arrangements for post mortem examination (e.g. when, where, who by if possible. This information may not be available until later or the next working day);
  • Liaise with parents about mementos if these have not been taken in A&E;
  • Liaise with family regarding retention of tissue and organs and obtain necessary signatures;
  • Ensure, in liaison with the paediatrician, that all medical records are forwarded to the paediatric pathologist prior to the PM;
  • Ensure parents are aware of available support organisations;
  • Attend the post mortem examination if necessary (e.g. forensic);
  • Liaise with pathologist regarding histology etc and ensure family, paediatrician and GP are updated as appropriate;
  • When post mortem report is received from pathologist, forward copy to paediatrician, police SIO, GP, family (if they have requested one);
  • Obtain reports and statements for inquest (it relevant).

Officers should at all times be sensitive in the use of personal radios and mobile phones, etc. Whenever possible, the officers liaising with the family, whilst remaining contactable, should have such equipment turned off. Remember not to use Police jargon or phrases like "crime scene" and "scenes of crime officer" within the hearing of the parent or carer. These terms can be very distressing for parents who have done nothing wrong.

Explain to the parents or carers that your attendance at such deaths is routine, and that you are trying to determine how the child died. Consider the general advice given in General Advice for Professionals when Dealing with the Family section.

It must be established whether the child's body has been moved and the current position (of the child) should be recorded. All other relevant matters should also be recorded.

An early record of events from the parent or carer is essential, including details of the child's recent health. All comments should be recorded. Any conflicting accounts should raise suspicion but it must not be forgotten that any bereaved person is likely to be in a state of shock and possibly confused. Repeat questioning of the parent/carer by different police officers should be avoided at this stage if at all possible.

The Scene

The preservation of the scene and the level of investigation will be relevant and appropriate to the presenting factors.

Officers initially attending the scene should ensure it is preserved until the DI attends. Any relevant items should be drawn to their attention, but the DI will decide what items will be retained and removed from the scene.

Consideration should be given to:

• Commencing a scene log;
• Photographs/video of the scene;
• Only retain bedding if there are obvious signs of forensic value such as blood, vomit or other residues. The routine collection of bedding is neither necessary for any investigative purpose, nor appropriate for the family;
• Retain items such as the child's used bottles, cups, food or medication;
• The child's nappy and clothing should remain on the child but arrangements should be made for them to be retained at the hospital. If the nappy has already been removed from the baby prior to police arrival ensure that it is recovered from the parents and handed to the paediatrician at the hospital for possible laboratory investigation. There is no need to retain any other clothing unless the baby's clothes have been changed prior to the arrival of the police;
• Records from the ambulance monitoring equipment which may be of evidential value; it is possible this information may only be retained for 24 hours.

The above is NOT an exhaustive list of considerations and should be treated only as a guide. They will not be necessary in every case. Refer to the earlier section "Factors which may arouse suspicion"

If it is necessary to remove items from the house, do so with consideration for the parents. Explain that it may help to find out why their child has died. Ask the parents if they want the items returned.

Record any environmental features which may indicate neglect or could have contributed to the death such as temperature of scene, condition of accommodation, general hygiene and the availability of food/drink.

At home, unless the death is clearly unnatural, there is no reason why parents cannot hold their dead child. This should however take place under the discreet observation of a police officer.

Offer to contact friends or relatives who might support parents, and employers to explain absence.

Other Issues

A G5 (Report of Death Form) must be completed at an early stage. This will be completed by the Coroner's Officer if they are in attendance. However, in order to avoid delay, it may be appropriate for the police officer present to complete the form.

Questions regarding the child's recent health can be recorded on the G5 under the appropriate heading. These questions should include the basic medical history of the child and family. Other relevant details which are thought to be pertinent to the child's death should also be included, an example of this could be when the child was last fed.

The issues of the continuity of identification must be considered. This will preferably be done by the Coroner's Officer but could be done by a police officer and should be carried out appropriately and sensitively.

Away from the scene*

Normally the Ambulance Service will transport a child's body from the scene to an A&E department. However, on rare occasions this may not occur, and the child's body may be taken to a mortuary.  This could be appropriate in circumstances where an older child has died (16-18) and it is clear what the cause of death is likely to be, for example suicide by hanging.

Any decision to take a body directly to a hospital or a mortuary, must only be made following a discussion with a consultant paediatrician in order to consider the need for an examination of the body, what tests should be arranged, and for medical information to be collated. However, where the cause of death appears explained, for example, following a road traffic collision, or where a Home Office pathologist has examined a body prior to arrival at the hospital, the examination and collection of samples by a paediatrician is unlikely to be necessary.

If the parents/carers wish to accompany the child's body from the home to the hospital, then this should be facilitated, unless the death is viewed as unnatural. Ensure that they are accompanied by police or coroner's officer. On those occasions a parent/carer may insist on physically holding the child whilst going to the hospital again this should be allowed, but they must be in car under the control of a police officer.

Police officers need to be aware of other professionals' responsibilities, i.e. resuscitation attempts, taking details from the parents, examination of the dead child and looking after the welfare needs of the family. Officers may need to wait until some of these things have happened and take details from these professionals before being introduced to the parents. This is where liaison and joint working is essential as there may be urgent evidential reasons why the police need to take immediate action. It is strongly advised that the Safeguarding Investigations Unit is utilised for such liaison wherever possible.

Subsequent Actions

Continue to maintain contact with the family and keep them informed of any developments.

Joint home visit (See Early Joint Home Visit for Unexpected Deaths of Young Children)

Following the unexpected and unexplained death of a young child under 2 years, all families should be visited at home within 24-48 hours by a paediatrician or other health professional, together with the police officer responsible for investigating the child's death or their representative. The purpose is to gather more information about the child, family and circumstances of death and to offer initial support. The police are responsible for contacting a local paediatrician to arrange this visit.

Where the unexpected death of a child under 2 is explained following initial enquiries, or the child is older than 2 years, a joint visit may not be done routinely, but may be considered. In all cases the need for any joint visit must be discussed with the consultant paediatrician, usually at the immediate information sharing and planning discussion.

Immediate information sharing and planning discussion (See Inter-Agency Working, Immediate Information Sharing and Planning Discussion)

When a child dies unexpectedly the police should initiate an immediate information sharing and planning discussion between lead agencies (i.e. health, police and children's social care) to decide what should happen next and who will do what. This discussion will normally be arranged by the Safeguarding Investigations Unit DS, so it is important that they are informed about all unexpected deaths of children at the earliest opportunity.

Early case discussion (See Early Case Discussion section above)

A multi-agency case discussion will be convened by children's social care as soon as the initial post-mortem result is known to share information relevant to the investigation of the death, and plan support of the parents. The police officer responsible for investigating the child's death or their representative must be present at this meeting.

Late inter-agency case discussion (See Late Multi-Agency Case Discussion section above)

As soon as the final post-mortem result is available  a further inter-agency meeting should be held to review the findings of the post-mortem report and any other information gained about the child, their family and the circumstances leading to the death. When appropriate, this meeting will mark the closure of the investigation into the child's death.

This meeting should be arranged by the children's social care. The precise timing will depend on the progress of the police/coroners investigations.

This meeting should include the paediatrician involved, the GP, health visitor, coroner's officer, other relevant health professionals, children's social care, police and any other appropriate agencies.

Retained items

When enquiries are completed, and unless they are required to be retained for any inquest, at the earliest opportunity, any articles taken from the scene that the family wish to retain should be returned to them.

Ensure that all police documentation is removed, and that the property is returned in new and appropriate bagging. Appropriate bags are retained in the Safeguarding Investigations Unit offices.  If soiled articles were taken, ask the parents about their return, and if  they would like them to be cleaned. If so, arrange for any items to be cleaned before their return, but remember that some parents do not want items cleaned prior to their return.

Always make an appointment with the parents to return any property, and remember this could be a significant event for them.

Always make an appointment with the parents to return any property, and remember this could be a significant event for them.

Ensure all the relevant documentation is contained in the C5 family file, which should be clearly marked "child death in family". An overview report concerning the investigation must be completed by the Safeguarding Investigations Unit DS, and submitted to the SIU DI.

Ambulance Staff

Introduction

Attending the unexpected death of a child or baby will always be a difficult incident to manage. The situation will be highly charged and emotionally stressful so it is important that all practitioners who may come across this scenario are confident about what to do.

Response

The ambulance service communication centre will immediately notify the police control room when there is a call to the scene of an unexpected child death.

The recording of the initial call to the ambulance service should be retained in case it is required for evidential purposes.

Ambulance staff should follow the Joint Royal Colleges Ambulance Liaison Committee Guidelines and the South East Coast Ambulance Service Child Protection Procedures.

• Do not automatically assume that death has occurred, clear the airway and if in any doubt about death apply full cardiopulmonary resuscitation;
• Transport the child to an accident and emergency department *(see below);
• Inform the accident and emergency department giving estimated time of arrival and patient's condition;
• Record how the body was found - including the position of the child (e.g. prone) clothing worn and the reported circumstances;
• Note any comments made by the carers, any background information given, any evidence of possible substance misuse and the conditions of the living accommodation;
• Pass on all relevant information to the accident and emergency department receiving doctor and to the police.

Any suspicions should be reported directly to the police and the receiving doctor at the hospital as soon as possible.

*All children who suffer cardiac and respiratory arrest must be taken to hospital, this will not be a difficult decision on most occasions as the child or baby will be actively resuscitated. However, there are some occasions, although extremely rare, when the decision is made not to resuscitate, historically these cases have been left at home, it is vital that now, even these cases are transported to hospital This does not mean that resuscitation should be undertaken just to facilitate transport.

The reason for this is to enable the process for investigating the cause of death to start as soon as possible after the event. It has been shown that cell and tissue deterioration occurs extremely quickly in children and this can have a dramatic effect on whether a definitive cause of death can be found. This, of course, must be dealt with as sensitively as possible.

In these circumstances the crew should:

1. Explain fully the reason for transport to hospital to the parents;
2. Inform the receiving hospital via a pre-alert through the Emergency Despatch Centre (EDC) before leaving scene. EDC should make arrangements with the paediatrician on duty to meet the family, usually within the A&E department;
3. Update the police regarding the movement of the patient if they are not already present;
4. Drive under routine driving conditions, ensuring the comfort of the accompanying parents/ carers as much as possible.

Parents have the right to find out what has caused their child to die and getting the investigation underway as soon as possible will give them the best chance of getting that answer.

The only exceptions to the above would be when the death has occurred following planned end of life or palliative care, or when the cause of death is very obvious such as in the case of severe trauma. Under these circumstances transfer to local mortuaries (under the direction of the police) or leaving the patient at home will remain the appropriate course of action.

General Practitioners

There are times when a GP is called to the child first. In such circumstances the GP should adhere to the same general principles as the ambulance staff (see above).

It is essential for the GP to contact the police or Coroner's officer if they are the first on the scene, after taking into account their primary responsibility of saving life or declaring death. The best route is the Police Call Centre.

A GP may not issue the death certificate in these circumstances. Children who have died without explanation should be seen in the Accident and Emergency Department by a paediatrician and not sent directly to the mortuary. This enables the clinical history, examination and any initial investigations to be completed and information given to parents.

Hospital Staff

Ensure that the child is taken to the appropriate area of the Accident and Emergency Department even if they appear to have been dead for some time. The child should not be taken straight to the mortuary.

Call the duty consultant paediatrician and the resuscitation team. Find out the identity of the people with the child and their relationship to the child. Use the child's first name.

Allocate a nurse to look after the family to keep them informed about what is happening. The nurse should record any medical or other information they obtain.

A detailed history and examination are extremely important in the process of trying to identify the cause of death. Appendix 1: Unexpected Death of a Child Clinical and Social Information provides a pro-forma.

A paediatrician should record a detailed verbatim history of events leading up to the death, past and recent symptoms, any resuscitation attempts at home and any family history of childhood deaths or serious illness.

A full examination should be undertaken by a paediatrician and a careful record of any findings made on a body chart, including:

• The child's general appearance, cleanliness, any blood or secretions around nose or on clothes;
• Marks on skin, bruises, abrasions, other injuries, skin conditions;
• Marks from invasive procedures or resuscitation attempts such as venepuncture, cardiac puncture or cardiac massage;
• Lesions inside the mouth including frenulum/frenum and identifying possible effects of intubation;
• Appearance of retinae, although these may not be clearly seen;
• Any signs of injury to the genitalia or anus.

During attempted resuscitation, various investigations may be initiated including urea and electrolytes, full blood count, blood sugar, blood culture and gases, blood, and urine for metabolic studies.

After death:

Routine minimum samples to be taken immediately after Sudden Unexpected Deaths in children under 2 years - 2004 National Working Party Recommendations¹

Take blood from a venous / arterial site if possible e.g. femoral vein. Cardiac puncture can make PM findings difficult to interpret

Click here to view Table 1

Delays can compromise or invalidate cultures and metabolic tests

Virology samples must be sent to an appropriate laboratory.

Skin biopsy for fibroblast culture should be taken routinely (See Appendix 1: Unexpected Death of a Child Clinical and Social Information).

The following guidance about medical investigations following the death of an older child has been given by the Depts of Histopathology Great Ormond Street Childrens Hospital and of Paediatric Metabolic Medicine Guy's Hospital 2009.

1. Where there is any possibility of infection, the taking of samples shortly after death may improve the chances of growing the organism responsible.  In these circumstances, blood cultures, throat and nose swabs should be taken routinely in A/E. CSF should be collected if the clinical information suggests that meningitis is a possibility;
2. Unless the death is clearly unnatural, full metabolic investigations, as described in the protocol above, are indicated;
3. Always consider sending blood for toxicology.

If the post mortem is to take place within 24 hours of death, arrangements can be made by the paediatrician for samples to be taken by the pathologist.

A full skeletal survey will be arranged at post mortem. However, consideration should always be given to undertaking a full skeletal survey before the post mortem if there is particular concern that the death of a young child may have unnatural causes. An urgent opinion from a specialist radiologist is then appropriate. Abnormal findings may affect the management of any siblings, and the required investigations. Individual Coroners have made their own arrangements for local skeletal surveys.

For all children keep all clothing removed from the child in labelled specimen bags and give to the senior police officer. The clothing may assist the pathologist and occasionally be required for forensic examination. Clothing may not be returned to the parents until the Coroner agrees.

The child's body should not be washed or cleaned as this may interfere with the pathologist's investigation. How well the baby has been cared for and the presence of secretions or substances on the face may be important.

Mementos should be offered routinely. If there are marks on the child's body which might be masked by taking mementos these areas must be avoided.  Details must be sent to the pathologist (e.g. lock of hair cut or palm or sole prints taken). If mementos are not taken in A&E the Coroner's officer should be notified and a request made for them to arrange these after the post mortem.

The doctor who declares death cannot issue a death certificate and must inform the Coroner or Coroners' Officer about the death.

The paediatrician should send the pathologist details of the child's recent and  past medical history, resuscitation attempts at home and hospital including needle sites, any physical findings and any investigations. A pro-forma for this is available in Appendix 1: Unexpected Death of a Child Clinical and Social Information. A copy of this should also be sent to the Coroner.

Check if child is known to children's social care

The Accident and Emergency department should check if any of the family are known to children's social care.

A member of staff should keep the parents informed about what is happening.

When the child has been pronounced dead, the paediatrician should break the news to the parents and review the child's history. The paediatrician should explain that investigations will be done into possible medical causes of the death, that the Police and Coroner also have to investigate the death, and that the Coroner will order a post mortem by a pathologist with special expertise.

Parents should be informed that sometimes there is a delay of several days before the post mortem and that their child may need to be transferred to another hospital for this. They should be told that the Coroner's Officer is the Coroner's representative and will keep them informed. Parents should be given a copy of the DoH leaflet on post-mortems. They need to know that a police officer and paediatrician or other heath professional will visit at home.

Parents should be encouraged to hold and spend time with their baby/child. If resuscitation has been attempted, intravenous and intra-arterial lines and endotracheal tube should be removed (checking the tube had been correctly placed). Professional presence should be discreet during parents' time with their child.

Accident and Emergency staff will discuss how the parents are getting home and will inform all relevant professionals and agencies about the death, (i.e. GP, health visitor, records departments etc) and discuss contacting friends, family, employers etc.

Follow up by paediatrician

After the unexpected death of a young child an early joint home visit by a consultant paediatrician or designated nurse and a police officer will be organised by the police. See Inter-Agency Working. The aim is to review the medical history and circumstances of the death, address parents' early questions, establish future communication with them and identify sources of support.

The paediatrician should inform the GP and health visitor about their involvement and follow up plan.

Post Mortem Results

The Coroner's Officer will provide the consultant paediatrician with preliminary post mortem results. They will send them a copy of the final post-mortem report together with confirmation from the Coroner that they can discuss this with the family. The paediatrician may have to contact the Coroner's Officer to request these.

Immediate information sharing and planning discussion (see Inter-Agency Working, Immediate Information Sharing and Planning Discussion).

Early case discussion (see above)

Late inter-agency case discussion

As soon as the final post-mortem result is available, children's social care will arrange a further inter-agency case discussion including the GP, health visitor, paediatrician, police and other relevant professionals to review the outcome of the investigation and follow up. See Inter-Agency Working.

The paediatrician is responsible for chairing the meeting and producing a summary for all the agencies. The paediatrician should advise the family about any further investigations for metabolic or genetic conditions in surviving or future children.

If Child is taken Direct to Mortuary

Any child whose death is unexpected should be taken to the Accident and Emergency Department to confirm that no resuscitation is possible and to address medical, child protection and bereavement issues. If, for some reason, a child's body is taken directly to the mortuary, the mortuary will inform the police.

The Safeguarding Investigations Unit will then be informed and will contact the duty consultant paediatrician.

The paediatrician's role includes taking a full medical history and if possible, conducting a brief clinical examination and arranging any appropriate initial investigations and an early joint home visit. The aim is to help identify at an early stage possible underlying medical conditions or child protection concerns.

Most acute life threatening events have a medical or physiological basis, although a precise explanation is not always found. Some have unnatural causes and assessment should always include consideration of these through careful history taking, examination and investigation similar to the list for unexplained deaths.

Child protection checks must be initiated for the child and any siblings. Any suspicions must be reported immediately to the duty social worker.

If there are no suspicious circumstances, after an evaluation of initial information;  from the ambulance service, hospital and previous records, primary care, police and children's social care records - the post-mortem should be conducted by a  pathologist with special expertise in paediatric pathology. If possible the post-mortem should be completed within 48 hours of the infant's death. If during the post-mortem the pathologist becomes at all concerned that there may be suspicious circumstances, they must halt the post-mortem and inform the Coroner.

If the Coroner has any concerns, having been made aware of all the facts, that the death may be of suspicious nature, then a Home Office pathologist will be used in conjunction with a paediatric pathologist. Where a pathologist is qualified both as a forensic and paediatric pathologist they may complete the post-mortem on their own.

Both the Coroner and the pathologist must be provided with a full history at the earliest possible stage. This will include a full medical history from the paediatrician, any relevant background information concerning the child and the family and any concerns raised by any agency. The Investigating Officer is responsible for ensuring that this is done. A pro-forma is available for the paediatrician. The medical notes will also usually be sent/taken to the pathologist by the police officer attending the post-mortem.

The Coroner's Officer should inform all relevant professionals of the time and place of the post-mortem, including the Senior Investigating Police Officer and consultant paediatrician. The family should also be informed.

The Investigating Officer should attend the post-mortem. If this is not possible, then he/she must send a representative who is aware of all of the facts of the case.  A full Scenes of Crime Officer team, including a photographer, must attend all post-mortems conducted by a Home Office pathologist.

A number of investigations will be arranged by the Pathologist at post-mortem. If the paediatrician has arranged any medical investigations before or after death, the pathologist and Coroner must be informed and the results forwarded.

All professionals must endeavour to conclude their investigations expeditiously. This should include the post-mortem results such as histology. The funeral of the dead infant must not be delayed unnecessarily.

The interim or final findings of the post-mortem should be provided immediately after the post-mortem examination is completed. The interim result may well be "awaiting histology/ virology/ toxicology" etc.

The final result must be notified in writing to the Coroner as soon as it is known. The final report should then be sent to the Coroner within seven to fourteen days of the final result being known.

When a Home Office Pathologist has been used, the pathologist should provide an interim report within two working days of the post-mortem, either orally or in pro-forma. A full written report should be provided to the Investigating Officer, normally via the Coroner, within 15 days or receipt of the exhibited photographs. Where the scientific examination extends beyond 20 days of the post-mortem, the Investigating Officer should be informed.

The Coroner's Officer will arrange the release of a copy of the report to the paediatrician, A&E consultant, and police with the permission of the Coroner.  In cases where an inquest is to be held, the Coroner may not be prepared to release a copy of the report until the Inquest is concluded.

The Investigating Officer should ensure that a copy is forwarded to the Safeguarding Investigations Unit for inclusion on file for future reference. The report must not be shared with other agencies without the permission of the Coroner.

Other sources of information

Leaflets

When a baby dies suddenly and unexpectedly

Download from www.lullabytrust.org.uk

The Lullaby Trust
Artillery House
11-19 Artillery Row
London, SW1P 1RT
020 7222 8001

A guide to the post mortem examination procedure involving a baby or child -

Department of Health Publications
PO Box 777
London SE1 6XH

Memory folder
Child Bereavement Trust
Aston House
West Wycombe
High Wycombe, Bucks HP14 3AG

The Lullaby Trust has a 24 hour helpline offering support and information to anyone who has suffered the sudden death of an infant.

The helpline is also available for family and friends and those professionals involved with the death. The telephone advisors personally answer the telephone every day of the year.

The Foundation has a wide range of leaflets and information for bereaved families and professionals. It also has a network of befrienders who are previously bereaved parents. Arrangements can be made for a befriender to contact the bereaved family to offer additional support.

Address:

11 Belgrave Road
London
SW1V 1RB

Helpline: 0808 802 6828
General: 020 7802 3200
Fundraising: 020 7802 3201
Press office: 020 7802 3202

Email: office@lullabytrust.org.uk

Website: www.lullabytrust.org.uk

Click here to view Appendix 1: Unexpected Death of a Child Clinical and Social Information