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9.2 The Management of Sudden Unexpected Deaths in Childhood (SUDC) *

*(Children aged under 18)

 

SCOPE OF THIS CHAPTER

Part I: Guidelines
This part covers the principles and practice of the management of sudden unexpected death in children being those under 18 years of age.

Part II: Roles and Responsibilities
This part covers individual's roles and responsibilities in relation to the management of a sudden unexpected death in childhood.

This protocol has been drawn up in consultation with:

  • Blackburn with Darwen Safeguarding Children Board;
  • Blackpool Safeguarding Children Boards;
  • Lancashire Safeguarding Children Board.

The efforts of all who have contributed to the preparation of this document are acknowledged and appreciated.

AMENDMENT

In May 2015, a link was added at Section, 8.1.2 to the ACPO Guide to Investigating Child Deaths.


Contents

Preface

Part I: Guidelines (Principles and Practice)

1. Introduction
2. Definitions
3. Contact Numbers
4. General Considerations
5. Factors that Suggest a Death may be Suspicious
6. Recommended Sequence of Events for Rapid Response Process
  6.2 Rapid Response Process
  6.3 Examination of the Body
  6.4 Organ Donation
  6.5 The Multi-Agency Discussion
  6.6 The Home / Place of Death Visit
  6.7 Post Mortem Examination
  6.8 Case Discussion Following the Preliminary Results of the Post Mortem Examination
  6.9 End of Case Discussion Meeting

Part II: Roles and Responsibilities

7. Role of the SUDC Nurse
8. Role of the Police
9. Children's Social Care
10. Ambulance Guidelines
11. The Hospital Staff
12. The General Practitioner (GP)
13. Community Health Professionals
14. Midwife
15. The Coroner and Pathologist
16. Parent Support and Communication
17. Information Sharing
18. Definitions / Glossary 
19. References
  Appendix 1 - Support for Staff Following the Death of a Child
  Appendix 2 - Information Sheet: Organ Donation
  Appendix 3 - Sudden Unexpected Death in Childhood (SUDC) Full History Record


Preface

The death of any infant, child or young person is a tragedy and devastates families and communities. The LSCB has a mandate to enquire into and evaluate unexpected child deaths. The investigation is initially to understand why a child has died and in the longer term to develop prevention strategies to keep the children of Lancashire safe.

Working Together to Safeguard Children 2015 sets out the strategic aims for a multi agency Rapid Response. This ensures that critical information is appropriately gathered by agencies involved with the child's death and shared on a timely basis with other organisations. The following guidance sets out the roles and responsibilities of the various agencies and is borne out of respect for life and attempts to prevent future child deaths.

All Agencies Responsibilities

It is imperative all agencies comply with and contribute to all aspects of the Rapid Response Process as pertinent to their role.

Multi-agency working is a statutory requirement and is imperative for the Rapid Response process to be effective. It is fundamental that agencies work together and share information to support a thorough investigation into why a child has died, to ensure that the bereavement needs of the family are met and that lessons are learnt where appropriate. (See Appendix 2 - Information Sheet: Organ Donation).


Part I: Guidelines (Principles and Practice)


1. Introduction

1.1 The sudden and unexpected death of any person demands a thorough investigation of the highest standard. A sudden and unexpected death in childhood (SUDC) is no exception. For the purpose of this Protocol a child is defined as a child or young person from birth (excluding both those babies who are stillborn and planned terminations of pregnancy carried out within the law) up to the age of 18 years.
1.2 All cases of unexpected deaths will receive a Rapid Response. Although this guidance applies to most cases, specific circumstances may dictate the investigation and multidisciplinary approach deviates from the guidance after due consideration and discussions with relevant professionals such as the Coroner, police, clinicians and colleagues from other agencies. All decision making processes should be documented to inform the Child Death Overview Panel (CDOP). Whatever actions are taken by the relevant agencies, adherence to recommended procedures will be under public scrutiny at any criminal trial or the Coroner's inquest. 
1.3 This protocol does not include expected deaths due to natural diseases processes. In those cases of children with existing life threatening conditions or complex needs which threaten life, and the child dies in a manner or at a time that was not anticipated, the Rapid Response Team will 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.
1.4 This document complies with, and should be read in conjunction with, Working Together (2015) and for the Police the ACPO guidelines on the investigation of infant deaths.

1.5

Principles

When dealing with sudden unexpected child death all agencies need to follow the following common principles:

  • A sensitive, caring, open minded and balanced approach;
  • An interagency response;
  • Sharing of information;
  • Appropriate response to the circumstances;
  • Preservation of evidence.

1.6

Aim

  1.6.1

This protocol provides a framework for the investigation and care of families after all unexpected deaths in childhood. The guidance explains the multidisciplinary approach necessary to achieve:

  • Sensitive care and support to all affected by the death;
  • Preservation of evidence at the place of death;
  • Full documentation of all interventions by paramedical and medical staff, including resuscitation prior to the certification of death;
  • The completion of a full medical history by medical staff;
  • A full review of all relevant agencies records;
  • A paediatric pathologist (and if necessary a forensic pathologist) investigating the cause of death;
  • Multidisciplinary case discussions proportionate to the circumstances of the death.
1.7 This guidance should be used for the sudden and unexpected death of a child under the age of 18 years irrespective of wherever the death occurs.


2. Definitions

See Definitions/ Glossary.

3. Contact Numbers

The specialist nurses for Sudden Unexpected Death in Childhood provide Service across pan-Lancashire and can be contacted Monday-Friday, 9am - 5pm. They can be contacted 01772 777220. (If reporting a new SUDC please ask for the mobile number for the SUDC Nurses.)


4. General Considerations

  • No matter how brief your time with the family, your attitude and actions will be remembered;
  • Maintain a supportive attitude whilst retaining professionalism;
  • Grief reactions will vary; individuals may be shocked, numb, withdrawn or hysterical;
  • Always refer to the child by name;
  • Handle the child with naturalness and respect, as if the infant/child were still alive;
  • In all but exceptional circumstances, such as when crucial forensic evidence may be lost or interfered with, parents and carers should be allowed contact with a dead child but an appropriate professional should be discreetly present with the family as the child is handled;
  • Deal sensitively with religious beliefs and cultural differences, while remembering the importance of evidence preservation;
  • Carers and parents will need to be given time to ask questions;
  • Give written information for the family (including the CDOP Leaflet);
  • Practical issues will need to be addressed (where the infant/child will go, what will happen, when the parents will see their child);
  • In most cases a post mortem will be performed;
  • If there are suspicious circumstances it is essential to secure and preserve crucial evidence for an effective investigation to occur In these situations, utmost co-operation from the parents/carers is required and there is a need for obtaining witness statements promptly;
  • If Child Protection concerns are identified, the safety of the siblings and other potentially vulnerable children must be prioritised and a referral to Children's Social Care must be made;
  • The emotional impact on a professional who worked with the child or family should not be overlooked or minimised in any way (see Appendix 1).
4.1

All professionals attending a child death, whether in the community or in the hospital setting, must abide by the following principles:

  • If the child shows any signs of life or where resuscitation is indicated, this should be commenced and the child should immediately be taken to the nearest Emergency Department (ED);
  • In all cases the child's body must be then brought by ambulance to the ED department. Occasionally a body may need to remain at the scene in suspicious cases, and this must be determined by the SIO;
  • In most cases the Consultant Paediatrician or the ED Consultant will meet with the parents and collect the detailed information as per the procedure;
  • All child deaths are reviewed by the Local Safeguarding Children Board (LSCB) Child Death Overview Panel (CDOP). In some cases consideration may be given as to whether a Serious Case Review is appropriate. This will be considered by the chair of the Local Safeguarding Children Board;
  • The authority for requesting a paediatric post mortem rests with the Coroner. Any samples taken at the post mortem, unless seized under Police and Criminal Evidence Act (PACE), are under the control of the Coroner. The SUDC Nurse will discuss Rapid Response elements and the post mortem process (where appropriate) with the family. SIO authority is required before a Home Office post mortem is arranged;
  • Due consideration should be given to identifying the needs and risks to other children in the family and ensuring their safety, a referral to Children's Social Care should be made where appropriate;

  • All individuals and agencies should ensure that their actions are legal, necessary, relevant and proportionate in order to comply with the Children Acts (2004) and the Human Rights Act (1998);

  • Due consideration should be given to the possibility of organ/ tissue donation. The fact that the death is unexpected and subject to a coronial and/or criminal investigation is NOT an absolute bar to the consideration of organ and/or tissue donation (Human Tissue Act 2004;). A discussion must take place with the coroner (see Appendix 2);
  • Ensure cross border communication is robust.


5. Factors that Suggest a Death may be Suspicious

5.1

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

  • Previous child deaths. However, there are some rare genetic disorders, which can cause multiple cot deaths within a single family. In such cases, an extended family history should be obtained and the involvement of a clinical geneticist may be helpful;
  • Previous Child in Need issues and/ or Child Protection concerns within the family relating to this child or the siblings;
  • Any previous life threatening event (ALTE);
  • Delay in seeking help without adequate explanation;
  • Inconsistent Explanations:
    • The account given by the parents/carers of the circumstances of death should be documented verbatim. Any inconsistencies in the story given on different occasions should arouse suspicions, although it is important to bear in mind that some inconsistencies may occur as a result of the shock and trauma caused by the death;
    • Explanations as to how the injuries occurred should be placed under detailed scrutiny when:
      • The explanation changes with time or questioning; or
      • The 'accident' was beyond the child's development (e.g. between 2 and 8 months children are not usually walking and therefore do not fall over unaided! They can of course fall from a height).
  • Evidence of parental drug/alcohol abuse, particularly if the parents/carers are still intoxicated;
  • Evidence of significant parental mental health problems;
  • Evidence of fabricated/induced illness;
  • An examination of the child should seek to establish any unexplained injury, including (taking into consideration the resuscitation process):
    • Any evidence of major bleeding or injury (cranial, bony, visceral or soft tissue) is highly suspicious unless proved otherwise;
    • The presence or otherwise of unexplained bruising/burns/bite marks including:
      • Multiple bruises to the face, ears, limbs or the trunk;
      • Finger print bruises and linear bruises are highly suspicious;
      • The frenulum - the narrow fold of mucous membrane preventing the lips from moving too far away from the gums - can be torn through such actions as force-feeding;
      • Petechial haemorrhages may or may not be present with suffocation and its absence is not conclusive either way but their presence should be noted and discussed with the paediatrician, ophthalmologist or pathologist (see Glossary of Terms);
      • A small amount of bleeding and froth around the mouth and nose may be normal. However, a lot of blood should be treated with suspicion. In either case medical opinion should be sought;
      • When on any other part of the body the injuries are burns, scalds, bite marks or injuries to bone.
  • Neglect issues:
    • Observations about the condition of the accommodation, general hygiene and cleanliness, the availability of food, adequacy of clothing and bedding and temperature of the environment in which the child is found are important. This will assist in determining whether there may be any underlying neglect issues involved. Historical information from a range of agencies should be taken into consideration about persistent concerns and adequacy of care provided to children, or adequacy of self care in parents should also raise suspicion about underlying neglect issues.
  • Shaking injuries:
    • These injuries present with non-specific symptoms ranging from apnoea, apparent life threatening event (ALTE), seizures, unexplained drowsiness and/or 'sudden loss of consciousness'. A high index of suspicion leads to identification of characteristic retinal haemorrhages on examination of fundii and subdural haemorrhage(s) on CT scan;
    • The photographs of the retina for signs of haemorrhage may prove invaluable. An experienced ophthalmologist may be able to differentiate between a shaking haemorrhage and one caused by brain swelling due to other causes;
    • During resuscitation, screening test for blood clotting disorders should be carried out promptly as brain injuries will eventually cause a similar effect. A photographic record should be made of all injuries immediately (and again after 24 hours).
  • Concealed births:
    • These types of deaths normally involve very young or mothers with serious mental illness giving birth 'unknowingly' until the onset of labour or in secret. A crucial part of any such investigation will be to establish whether the child ever had independent existence from the mother.
  • A photographic record must be made of all injuries immediately and a body map completed.


6. Recommended Sequence of Events for Rapid Response Process

6.1 See Recommended Sequence of Events for Rapid Response Process Flowchart.

6.2

Rapid Response Process

  6.2.1 A Rapid Response will be initiated for any child death which is in line with the Working Together 2015 definition of an unexpected death (the death of an infant or child (less than 18 years old) which 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 precipitating the events which lead to the death). The Rapid Response process is a co-ordinated inter-agency approach designed to obtain the best information possible to understand how the child has died. It will involve the early gathering of information, multi-agency sharing of information and discussion, review of the body, home/ scene visit (as appropriate), post mortem examination, support to parents and the follow-up multi agency meeting. The Rapid Response will be led by the SIO and/or SUDC Nurse, working closely with Children's Social Care. The Rapid Response process will vary in each child death, dependent on the case.
  6.2.2 Every SUDC should be taken to the nearest ED rather than the mortuary by the ambulance service, which allows for the earliest possible examination/assessment of the child. There are significant benefits to the family (and to the further investigation of the scene of the death) if the family and chid are immediately taken to a hospital emergency department with resident paediatric staff on site.  This will also ensure that the family receive appropriate medical and social support, and the protocol for investigation of the cause of the child’s death is implemented immediately (Kennedy, 2004).
  6.2.3 When removal of the child’s body has been authorised by the SIO the body should be wrapped in bedding from the child’s cot and placed in a suitably sized body bag with the child’s face exposed. The zip should only be fully closed after the body has been placed in the transfer vehicle (Guidance for Crime Scene Managers/ CSI, June 2012).  
  6.2.4 If there are suspicious circumstances, there is certainty that the child is dead and the SIO deems it appropriate that the body remains at the scene, the body will be removed at a later time to an appropriate mortuary. This will be clearly documented within the SUDC History Record. It is essential that the on-call paediatrician is notified of the child’s death and that the child has been taken straight to the mortuary.
  6.2.5 At the ED Department the Consultant Paediatrician / Registrar on call / the ED Consultant (in line with local policy) will notify the Police of the death. Following confirmation of the death in ED it is important that the history / presentation of the body is documented, including use of body maps by the clinician. Clothing (including any nappy) must remain on the infant/child. Wherever possible, any removal should be undertaken/supervised by a police officer, where the clothes have already been removed e.g. during medical intervention then they should be recovered.
  6.2.6 The Police and SUDC Nurse (when available) will attend immediately; a discussion will take place with relevant professionals. This will always include the consultant clinician.
  6.2.7 The parents/carers should be allocated a member of staff to care for them and should normally be allowed to hold and spend time with their child while in the ED department. Where possible mementos and keepsakes should be obtained at this point in agreement with the SIO.
  6.2.8 The SIO/SUDC Nurse will work together in the Rapid Response and in a suspicious case the SIO will hold primacy. Where the SUDC Nurse is not available (outside of Monday to Friday 9-5pm) the SIO will assume the SUDC Nurse responsibilities so far as possible until the next working day when the SUDC nurse is available. This will include where the child's home address falls outside one of the five Lancashire Clinical Commissioning Group geographical areas. The SIO must brief the SUDC Nurse at the earliest opportunity and make available all evidence gathered. All forensic considerations should be co-ordinated with the Crime Scene Investigation (CSI) Department as per The SUDC Crime Scene Guidance (June 2012).
  6.2.9 Upon notification the SUDC Nurse / SIO will gather information relevant to the death and begin to complete the History Record with the SUDC Nurse leading this task. The SUDC Nurse will contact all agencies that were involved with the deceased child and family. It should be quickly established if the child or family are an open case to Children's Social Care, known to the Police or Targeted Health Care Services. Examples of professionals to be contacted include:
  • The Safeguarding Team for the locality;
  • The Paediatrician;
  • The GP (child/ family/ out of hours);
  • Community Nurses - School Nurses- Health Visitors (and any other community paediatric professionals);
  • Children's Therapists;
  • ED;
  • Ambulance Service (The NWAS Safeguarding Team can be contacted for details of attending ambulance staff, or during out of hours the Emergency Operations Centre Duty Manager can be contacted);
  • Liaison Health Visitor (Hospital Based);
  • Midwives;
  • The Coroner;
  • Social Care (referral made if appropriate);
  • Education;
  • The Child Death Overview Panel Coordinator;
  • Mental Health;
  • School/ Early Years/ Youth Offending Team;
  • Drug and Alcohol Misuse;
  • 3rd Sector and Voluntary Sector Providers;
  • Palliative Care (if appropriate).
  6.2.10 This is not an exhaustive list and agencies contacted may vary dependent on each individual case. Acute, Community and Medical nursing notes will be crucial to inform the history record.

6.3

Examination of the Body

  6.3.1 If required and available the SUDC Nurse will support the investigation into why the child has died, by examining the body to identify any markings, any post mortem changes or signs of possible abuse or neglect that may not have been evident at the time of initial medical examination by paediatrician undertaken in ED department (including body mapping). This is usually carried out with the SIO. It is important to be aware of the resuscitation process involved to inform the interpretation of markings which may be due to resuscitation. As soon as practically possible the SIO should instruct the Crime Scene Investigation Unit to compile photographic evidence of the body. 
  6.3.2 Please note that post-mortem changes can occur rapidly and this should influence the timely completion of the body map ensuring that it is signed and dated by those present at the examination. Any documentation relating to the examination of the child’s body must be retained and disclosed to the police in the event of a criminal prosecution.

6.4

Organ Donation

  6.4.1 Many parents following the unexpected death of their child may ask about the possibility of organ donation. In all cases the decision whether or not donation can proceed is the Coroners to make, in consultation with the relevant SIO and treating hospital consultant. A criminal or Coroner's investigation takes precedence over donation but is not necessarily a bar to donation. If donation is possible, this should be discussed immediately with the Specialist Nurse for Organ Donation and Transplant Coordinator (See Appendix 2). The relevant consultant and SIO should then make contact with the Coroner in whose jurisdiction the body is lying.

6.5

The Multi-Agency Discussion

  6.5.1 The SUDC Nurse / SIO will conduct a multi agency information sharing and planning discussion with the key agencies and professionals who were involved with the child and family prior to the death and at the time of death. This will assist those involved to formulate a plan which will include safeguarding of any siblings, support for parents and maintaining the integrity of any criminal investigation. 
  6.5.2 This discussion is for the sharing of information and future planning. It is usually a telephone conversation given the fast moving pace of events after a SUDC (in some circumstances it will be appropriate for this to be a formal meeting).
  6.5.3 The purpose of the "Multi agency discussion" will be to:
  • Share information, either personal or from documentation which may shed light on the circumstances leading up to the child's death including the child's previous health, previous or unexplained deaths in the family, neglect or failure to thrive, unusual presentations of the child or parental substance misuse etc. Relevant information may also be discussed in respect of other family members and/or others involved with the child;
  • Plan any subsequent Joint Police and Local Authority Children's Social Care Investigation and set time scales for review of progress ensure SIO and SUDC Nurse are involved;
  • Enable consideration of any Child Protection risks to siblings / other children living in the household and referral within Safeguarding Children Procedures. It is critical that any medical or welfare needs for the family are assessed at this early stage;
  • Ensure a co-ordinated bereavement care plan for the family;
  • Consider welfare and support of staff;
  • Identify an action plan, outlining clear roles and responsibilities for the remainder of the Response, review forensic considerations;
  • Consider the need for further review.
  6.5.4 The discussions occurring at the meeting and any decisions made should be fully documented and information gained from all the agencies must be shared with the Pathologist and Coroner within 28 days of the child's death. The information collated during this discussion may also be necessary for any future Serious Case Review process and consideration by the Child Death Overview Panel. See also Child Death Overview Panel Procedure and Serious Case Review Procedure.

6.6

The Home / Place of Death Visit

  6.6.1 The SUDC Nurse and/or the SIO should discuss if a visit is to take place which should, in any event occur within 24 hours of the child's death. Prior to the visit commencing the professionals attending should decide who will lead the discussion with the parents and who will record the visit. At the outset of the visit the relevant professionals should be introduced to the family/ carers, their roles explained and the purpose of the visit is to 'find out why their child has died'. A detailed history of the activities leading up to the child's death (irrelevant of the age of the child) should be recorded as well as a detailed thorough account of the last sleep/final events. It is important for the professionals to work together in discussing events with the parents to gather a holistic history. The scene of death should be observed closely and where possible a reconstruction carried with careful identification of potential hazards and causative factors. Care should be taken particularly around discussions regarding post mortem concerns. Where possible, this should be done by the SUDC Nurse.
  6.6.2 Home visit de-brief and overview of information gathered must occur and be recorded to inform the investigation. Relevant information should be shared with all relevant agencies involved.

6.7

Post Mortem Examination

  6.7.1 The SIO will request an authorisation for a post mortem and the type of post mortem to be performed from the Coroner. The SUDC Nurse / SIO will fully brief the Pathologist(s) on relevant information obtained from whatever source, on occasion it may be appropriate for the SUDC Nurse to attend the post mortem examination. A copy of the SUDC nurse's report for the Pathologist will be provided at the earliest convenience. If the child's death is suspicious and the Response is led by the police, this report will also be shared with the SIO.

6.8

Case Discussion Following the Preliminary Results of the Post Mortem Examination

  6.8.1 Following the initial post mortem results becoming available the SUDC Nurse will convene a further multi-agency discussion (usually on the telephone). Permission from the coroner to share the post mortem findings must first be sought. This discussion should involve the professionals involved in investigating the child's death, in agreement with the coroner. They should review any further information which has become available and raise any additional concerns about safeguarding issues. This discussion will be documented in the History Record.

6.9

End of Case Discussion Meeting

  6.9.1 The SUDC Nurse will convene and chair the end of case discussion meeting. The meeting takes place when the final post mortem report is available and before the inquest is held Receipt of the post mortem report from the Coroner assumes that the Coroner has given permission to share the cause of death with the professionals involved. The type of professionals involved in this meeting / discussion depends on the age of the child. The meeting should include those who knew the child and family and those involved in investigating the death, for example, the GP, health visitor or school nurse, paediatrician(s), pathologist, senior investigating, police officers and social workers.
  6.9.2

The main purpose of the case discussion is to:

  • Share information,
  • Identify the cause of death and those factors that contributed to the death,
  • Plan future care for the family and identify lessons to be learnt. 
  • It must also be agreed what information will be shared, and by whom, with the parents – this will include a discussion in relation to the Post Mortem results which, (with the consent of HM Coroner), be discussed with the parents.
  6.9.3 The parents/carers will be informed that these meetings are taking place but will not be invited. However, parents/carers are encouraged to provide information to contribute to the discussion and feedback will be provided if requested by the most appropriate professional.
  6.9.4 An agreed record of this case discussion meeting and all reports will be sent to the coroner to be taken into consideration at inquest. This should also be made available to the CDOP. When a child dies away from their normal place of residence, a joint discussion will take place between the SUDC nurse and the LSCB in the area in which the child is normally resident.


Part II (Roles and Responsibilities)


7. Role of the SUDC Nurse

7.1 The role of the SUDC Specialist Nurses have been commissioned jointly by the Clinical Commissioning Groups across pan-Lancashire to develop and coordinate the health perspective required in the multi-agency response to assist in the investigation of SUDC. The insight gained from this multi agency response will influence service design, provision and planning around the SUDC agenda, improve practice and expertise, identify themes to reduce the incidence of child death across the county and contribute to Coroner's inquests and CDOP investigations to promote the welfare of children in the future.
7.2 Throughout the process it is imperative that all agencies keep the SUDC nurse involved in the developments within their own agencies of the case.
7.3

The SUDC Nurses will:

  • Complete the Rapid Response Process;
  • Provide advice to professionals in relation to classification of a death as unexpected. When in doubt, the processes for unexpected deaths should be followed until the available evidence allows a different decision to be made;
  • Convene the response to each child's unexpected death, initiating an immediate information sharing and planning discussion between the lead agencies;
  • Ensure the process of information gathering and information sharing amongst professionals from all agencies involved in each case, providing expert advice to all professionals regarding the Rapid Response process;
  • Coordinate and support parents and family throughout the process. This will include the provision of advice, referral to appropriate support agencies and support visits will follow as the case determines;
  • Offer support to staff involved in the rapid response and keep them informed of the SUDC process.
7.4 The SUDC nurse involvement with each case ceases after the inquest / End of Case Discussion / Meeting, when clear support plan is in place by appropriate services and a report is submitted to the Coroner.
7.5 The SUDC Nurse will notify NHS England, who will in turn notify the Care Quality Commission of an unexpected death (Working Together, 2015).


8. Role of the Police

8.1

Introduction

  8.1.1 The purpose of the police investigation is to firstly determine the circumstances surrounding the death and to ascertain whether there is criminal involvement by any person. Such deaths will always be treated initially as suspicious and remain so until determined otherwise. Secondly, in accordance with The National Police Chief’s Council guidance, on behalf of the Coroner.
  8.1.2 This document should be read in conjunction with the guidance on child deaths contained within the ACPO Guide to Investigating Child Deaths.
  8.1.3 In relation to all sudden and unexpected infant or child deaths the on duty/on-call accredited Senior Investigating Officer (SIO) will be informed and will retain overall responsibility for the investigation. The SIO must make contact with the SUDC Nurse to inform her of the death and initiate the Rapid Response Process.
  8.1.4 During SUDC nurse working hours the Detective Inspector (DI) together with the SUDC nurse responding will co-ordinate the appropriate response.
  8.1.5 A detective officer of at least Inspector rank (and preferably with Police Public Protection Unit experience) must attend the scene and take charge of the investigation. Additionally, this officer should be skilled in interagency working and must be conversant with these guidelines.
  8.1.6 It is important to remember that in the vast majority of child deaths, the cause is natural, therefore there needs to be a careful balance between consideration for the bereaved family and the potential of a crime having been committed.
  8.1.7 Police involvement may be likely to increase parents' levels of distress. They will require an explanation of the reason for police involvement. Officers should inform the parents that the police act on behalf of the Coroner and have a duty to investigate the circumstances of the death. Police involvement occurs in every case of sudden and unexpected infant/ child death and it is hoped the investigation will help identify how the child has died. In most cases parents will welcome any assistance in obtaining an explanation for their child's death and will wish to assist this process.
  8.1.8 There are certain factors in the history or examination of the child, which may give rise to concern about the circumstances surrounding the death (see Factors that Suggest a Death may be Suspicious). If any such factors are identified, it is important that the information is documented and shared with senior colleagues/ SUDC Nurse and relevant professionals in other key agencies involved in the investigation.
  8.1.9 In cases where there is a criminal investigation the SUDC nurses will share all the information/ documentation/material that they hold in its entirety in accordance with S1. Criminal Investigation and Procedure Act 1996 (CPIA).  

8.2

Initial Action

  8.2.1 Ensure all relevant scenes are preserved.
  8.2.2 The allocation of an officer to attend a reported death of a child must be carefully considered by the supervisor; who must ensure that the officer feels and is able to cope with such an incident (for example it may be inappropriate where the officer has also suffered the loss of an infant/child). Any representations made by an officer must be considered.
  8.2.3 Actions and behaviour of officers must be balanced. Officers at all times must be sensitive in the use of personal radios and mobile phones. (Be aware of inappropriate ring tones - feedback from a parent).
  8.2.4 Police attendance must be kept to the minimum required as several Police Officers arriving at the house could be very distressing. Wherever possible, officers in plain clothes should be utilised and/or the use of unmarked vehicles considered.
  8.2.5 A Lancashire Constabulary Form G72 - Report of Sudden Death must be completed before the request for a post mortem is made. Ensure that a copy of this form is shared with SUDC nurse.
  8.2.6 The officer must make a visual check of the child and its surroundings, noting any obvious signs of injury and any clothing or items on the body. It is important to examine and photograph the body at the earliest opportunity; this is usually performed at the ED department or the mortuary and should be captured by police CSI officer.
  8.2.7 Please note that post-mortem changes can occur rapidly and this should influence the timely completion of the body map ensuring that it is signed and dated by those present at the examination. Should there be any suspicion raised by paediatric examination of the deceased child, and it is felt appropriate then an ophthalmic expert may be requested.
  8.2.8 The SUDC Nurse will assist in the examination of the body to provide a health perspective, to help identify markings, post mortem changes and signs of neglect or abuse.  
  8.2.9 It must be established whether the body has been moved and the current position of the child must be recorded on the G72.
  8.2.10 Once death has been ascertained the child will be removed only following the permission of the SIO/ DI. In these cases removal of the body will be managed by CSI who will place the child in a suitably sized body bag with the face exposed. Where the child died in a cot/ bed the child will be wrapped in the bedding and the zip of the body bag will only be fastened when the body has been placed in the undertaker's vehicle/ ambulance (SUDC Scenes - Guidance for Crime Scene Managers/CSI's, Lancashire Constabulary, 2012).
  8.2.11 In the majority of cases the child will be taken to the nearest ED by the ambulance service. If there is any deviation from this process it must be clearly documented as to why. The child must always be accompanied by a professional.
  8.2.12 If the SIO believes there are suspicious circumstances and there is certainty that the child is dead, the child is left in situ until the SIO instructs otherwise.
  8.2.13

In addition to any other information the following information must be included on G72:

  • basic medical history of the child and family including any previous child death;
  • where the child was, the sleeping position and , if covered, with what;
  • what the child was wearing;
  • when the infant/child was last fed, by whom and food content;
  • if applicable, when the child's nappy was last changed, by whom and where is it now;
  • has the child been well up until time of death;
  • last seen alive by whom;
  • if applicable, what caused the adult to look/check the child;
  • temperature of the scene;
  • condition of accommodation;
  • general hygiene and availability of food and drink;
  • Parents: any alcohol/tobacco/medication – last taken/current state. In cases where alcohol is suspected or confirmed decision to arrest parents/ carers should be made in conjunction with SIO. See section on samples.  
  8.2.14 An early explanation from the parent / guardian / carer is essential; all comments must be recorded as any conflicting accounts will raise suspicion. However, it must be borne in mind that any bereaved person may be in a state of shock and possibly confused.
  8.2.15 Repeated questioning of the parent / guardian / carer by different officers must be avoided at this stage.
  8.2.16 It is entirely natural for a parent/carer to want to hold or touch the dead child, providing this is done with a professional present this should be encouraged, as it is unlikely that forensic evidence will be lost. If the death has been considered suspicious the SIO, should be consulted before a parent/carer is allowed to hold the child. All contact must be discreetly supervised and recorded.
  8.2.17 If, after the death has been confirmed, it is decided that the death should be referred to the Coroner, the Coroner has control of the body. Consequently, the SIO should be approached for lack of objection to any mementoes being taken to ensure forensic evidence is preserved and the Coroner then is asked to ensure that it will not interfere with his investigations.
  8.2.18 A professional from the hospital may refer a sudden and unexpected infant or child death following admittance via the ED Department or where the child has died on a hospital ward. In such cases, officers need to be aware that paramedics and health professionals will have examined and made attempts to resuscitate the infant or child. This involves a variety of medical equipment. Officers should also be aware that some medical equipment used as part of this process may still be attached to the infant's body, including 'drip' and 'other' injection equipment, but the tubes etc. will be cut to a short length. These should be left 'in situ' until removed by a pathologist. In cases where it is felt relevant officers should establish from the health professionals what medical equipment has been used and consider securing said equipment. Ensure that any paramedic/ health professionals witness details are shared with SUDC nurses. 
  8.2.19 In all cases HM Coroner/Coroners officer for the relevant area must be informed of the death normally during working hours but out of hours if the SIO deems contact necessary.

8.3

The Death Scene

  8.3.1

Where no suspicious circumstances arise as a result of initial actions, no further action in respect of scene preservation will normally be required. This will be the decision of the Senior Investigating Officer in conjunction with the DI who has attended the scene.

  • A Crime Scene Investigator (CSI) will be requested to attend. This is essential to capture all relevant evidence. See CSI guidance for SUDC scene on the Lancashire Constabulary intranet site;
  • Retain bedding (but only if there are obvious signs of forensic value, such as blood, vomit or other residues);
  • Recovering articles from the infant's/child's last meal, (including used bottles, cups, and food) and any relevant medication;
  • Consider taking bin contents, personal diaries and any photographic/ video footage etc. Where items are removed from the house, it must be explained to the parents that this may help to find out why their infant has died;
  • Clothing (including any nappy) must remain on the infant/child. Wherever possible, any removal should be undertaken/supervised by a police officer, where the clothes have already been removed e.g. during medical intervention then they should be recovered.
  8.3.2 The 'Personal Child Health Record' (or 'Red Book') should also be secured. The 'red book' is a parent owned record of the infant's development completed by health professionals, and is therefore not classed as confidential medical records. These books are relevant for children under 5 years.
  8.3.3 The SUDC Nurse will obtain up to date health information verbally from the Health Professional. If a copy of the Community health records is needed, then they will be requested from the Named Nurse or the Safeguarding Team.

8.4

Public Protection Unit - Child Abuse Investigation Unit

  8.4.1 Child abuse officers have specialist skills, knowledge and experience within the field of interagency child protection.
  8.4.2 In all cases of sudden unexpected infant or child death contact should be made as soon as possible with the local Public Protection Unit Detective Inspector/Supervisor.
  8.4.3 At the initial request of the Senior Investigating Officer the Child Abuse Investigation Unit Supervisor will be responsible for liaising with other agencies in particular Children's Social Care and Health.
  8.4.4 It will be the responsibility of the Public Protection Unit (PPU) to assess and deal with the need for any necessary protection of siblings. In cases where immediate protection is necessary, officers must adhere to the force policy on police protection powers (PPP) and a Medical examination of any siblings should be considered.

8.5

Hospital Procedure

  8.5.1 The Consultant Paediatrician on call/ ED Consultant will fully brief and provide the SIO/DI/ SUDC nurse with a summary of the child’s medical history, presentation and body map. If there is a requirement to challenge medical opinion at this point SIO/DI/SUDC nurse should contact the designated safeguarding paediatrician for a second opinion.
  8.5.2 The SIO / SUDC Nurse are responsible for ensuring that the Pathologist is provided with this summary. Any concerns regarding the history or presentation of the child should be raised with the pathologist at the earliest opportunity.
  8.5.3 The Rapid Response Team (SIO and SUDC Nurse) will have initiated the multi agency discussion to obtain further health and social history, including any relevant background information concerning the family and any concerns raised by any other agency. In complex cases a formal meeting will be required and should be attended by all relevant agencies.
  8.5.4 If the hospital has undertaken any investigations prior to the death the SIO must be informed who will then inform other interested parties (SUDC Nurse, H.M Coroner and Pathologist). These samples are under the control of the Coroner unless they are seized in accordance with Police and Criminal Evidence Act (PACE), which must be considered by the police as part of their evidence strategy. Consideration must be given in all cases to preserving or seizing time sensitive samples blood, serum, scans etc. which should be kept in conditions to maintain the integrity of the sample e.g. refrigeration for blood samples, preservation of digital images etc. It should be borne in mind that such samples may also be needed by organ donation teams, subject to the consent of the SIO and the authority of the Coroner. 
  8.5.5 When the infant/child is taken to the mortuary the body should be accompanied by a police officer. If the parents wish to accompany their infant/child to the mortuary, this should normally be facilitated but the parents must be accompanied by a Police Officer.
  8.5.6 To obtain copies of relevant hospital records, follow each Acute Trust's own procedures. Liaise with SUDC nurse to facilitate this.
  8.5.7 When considering taking samples from parents refer to section 62 of PACE which creates the authorisation to request intimate (blood, urine, body fluids and pubic hair) samples. Section 63 of PACE creates the power for non-intimate samples (hair other than pubic hair, nail swabs, saliva, a swab taken from any part of a person's genitals, or a dental impression) from any person in custody. In circumstances where an arrest is not appropriate at that time, consideration should be given to requesting and obtaining 'voluntary' samples of preserved and un-preserved blood and urine. In all cases where blood is requested (either under PACE or on a voluntary basis) this should be conducted by a Forensic Medical Examiner (FME) and not hospital staff. 
    8.5.7.1 When considering requesting samples on a voluntary basis from bereaved parents, section 78 PACE needs to be considered. There may be instances where it could be deemed unfair to obtain voluntary samples from distressed grieving parents and later use these against them in a criminal trial. Guidance from the SIO should be sought before this action is taken.

8.6

The Post-Mortem

  8.6.1 In all infant or child death cases HM Coroner has introduced the following guidance for undertaking a post-mortem examination and the decision will be final:
  • In non-suspicious cases a Paediatric Pathologist, if possible and available, will be instructed to conduct the post-mortem examination at a hospital notified by the Coroner;
  • In non-suspicious cases involving older children and adolescents or road traffic collision victims, the post-mortem may be carried out by a general pathologist at a hospital notified by the Coroner. If in doubt the Coroner should be consulted. If the post-mortem examination reveals suspicious circumstances, then it will be halted and the post-mortem continued jointly with a Home Office Pathologist;
  • If from the outset there is substantial suspicion, the SIO should personally contact the Coroner who will consider the request for the Coroner will direct a joint post-mortem, to be conducted by a Home Office Pathologist, who will take the lead, together with a Paediatric Pathologist at a hospital notified by the Coroner. The Police will ensure that the Coroner is notified as to whether samples taken at post mortem are taken under PACE (and have an exhibit number) or taken under the Coroner's authority and subject to the Human Tissue Act 2004;
  • In suspicious cases the SIO, following discussion with the Coroner, will arrange for a police Post-Mortem Team to attend the post-mortem, the team will include the SIO (or appointed representative), a home office pathologist, a Crime Scene Investigator and an exhibits officer. The pathologist will determine when a skeletal survey is to be performed. This is usually required for children under the age of two years and the SIO representative should ensure that a request is made for this to be done;
  • In all cases where a post mortem is to occur a copy of the CSI photographs obtained and any other relevant history/ documentation should accompany the body;
  • In all cases it is best practice to brief the pathologist along with the SUDC Nurse to brief the pathologist on all relevant information that has been gathered during the investigation, whether the case is deemed suspicious or not. Even when initially criminality is not a concern, risk factors may be evident that may help understand why the child has died. Post mortem findings may later indicate criminality;
  • The SIO/DI and SUDC nurse should be provided with the interim findings as soon as possible after the post-mortem examination is completed, whether these findings are conclusive or not;
  • The results of the interim findings should be conveyed to the family. However, bearing in mind possible legal implications arising from the findings, the Coroner will use his discretion as to what information will be passed to the SUDC Nurse and/or the Paediatric Consultant. The Coroner will endeavour to be as helpful as possible with the provision of information. The SUDC Nurse/Paediatrician may be instructed to keep some information strictly confidential. Discussion must take place between the SIO/ SUDC nurse and Coroners officer as to who is best placed to relay the initial post mortem information to the family;
  • The Coroner should make available to the SIO/DI/SUDC nurse a copy of the post-mortem examination final report as per local arrangements. Again, bearing in mind possible legal implications arising from the findings, the Coroner will use his discretion as to what information will be passed to the SUDC Nurse and/or the Paediatric Consultant. The Coroner will endeavour to be as helpful as possible with the provision of information. The SUDC Nurse/Paediatrician may be instructed to keep some information strictly confidential. Discussion should be had between the DI/ SUDC nurse and Coroners officer as to who is best placed to provide this information for the family.  In cases which culminate in an inquest, the information provided by the pathologist will be given at the inquest;
  • No other agency will be allowed access to the Post Mortem report without prior approval from the Coroner. Permission should always be sought by any agency if the content of the report could potentially affect the agency's future actions;
  • Please note that liaison with the receiving mortuary is vital in order to ascertain opening hours. Under no circumstances must bodies be delivered to them outside opening hours. There are often no facilities for long term storage and so close liaison is vital.
  8.6.2 As Part of the Rapid Response Process it is paramount that the SIO/DI and SUDC Nurse liaise as to the progress of the case and share any new developments or information.
  8.6.3 It is important that the SIO/DI contributes / attends the multi-agency End of Case Discussion.

8.7

Returning Property

  8.7.1 Items of property which have been seized should be returned as soon as possible after the Coroner's verdict or the conclusion of the investigation. Parents must be asked in person if they wish for them to be returned. The return of these items should be handled sensitively (for example, where a bottle containing feed or juice is taken, the bottle should be returned clean, rather than in its original state) and the family's wishes as to whether or not the items should be cleaned prior to return ascertained. Official labels or wrappings must be removed before return.

8.8

Welfare

  8.8.1 Police involvement with bereaved and traumatised families is amongst the most difficult of any situations an officer is called upon to deal with. It requires extreme sensitivity and may have a significant emotional impact on anyone coming into contact with the family including investigators. The Senior Investigating Officer must provide appropriate levels of support for every officer involved in this type of investigation regardless of outcome.
  8.8.2 It is recommended good practice that an immediate de-brief takes place, where needed, following a case where issues of practice are raised by any agency.
  8.8.3 SIO must complete Operation Marshall form (previously known as form 76.) This information feeds in to national data sets being developed to provide a clear picture based on common risk factors in deaths of children.


9. Children's Social Care

9.1 In the first instance ED staff will check with Children's Social Care whether the child or any child within the same family is or has been known to Children's Social Care and if so, in what capacity. As part of the Rapid Response Process the SUDC Nurse and /or SIO will also liaise with Children's Social Care Staff and ensure a senior manager is informed.
9.2 Children's Social Care staff will check whether the child has been previously known to social care and early intervention teams for any records which indicate any current or previous concern as to the wellbeing of the child or any other such child in the family. Information provided by Children's Social Care about any concerns should include which agency/agencies referred the concerns, what the concerns were, how it was responded to by Children's Social Care including actions and outcomes.
9.3 If the family of the deceased child are existing clients of Children's Social Care or have been, then any current or previously allocated worker will be informed, and will inform their line manager.
9.4 If the family is not currently known to Children's Social Care, the primary support to the family will be given by health professionals and/or the Police. However, should these agencies believe that other services are required then the Common Assessment Framework (or other local equivalent) process should be followed to identify the most appropriate service required.
9.5 If the death appears suspicious and where there are any concerns that another child or sibling has suffered or may suffer harm as a result of abuse then this should be referred directly to Children's Social Care as a Child Protection Referral, and a Child Protection Investigation will be initiated under sec 47 of Children Act 1989.
9.6 The Allocated Social Worker will liaise with the SUDC Nurse and the Public Protection unit, and share information.


10. Ambulance Guidelines

10.1 When the ambulance service is called to the scene of a sudden unexpected death of a child, the attending crew must notify the Ambulance Control Room. The duty Control Room Manager must notify the Police Control room.
10.2 The recording of the initial call to the ambulance services should be retained for evidence purposes.
10.3 The first ambulance staff at the scene should be aware that later they will be required to inform the police of any history obtained surrounding the death and to have noted the position of the child and the clothing at the time of their arrival.
10.4 Ambulance staff should not assume that death has occurred. If the infant, child or young person shows any signs of life, if there is any doubt about whether death has occurred, or where it is deemed that resuscitation is indicated, this should be commenced and the infant, child or young person should immediately be taken to the nearest ED.
10.5 The ambulance crew should inform the receiving Emergency Department of the child's condition and the expected time of arrival.
10.6 Where the ambulance crew diagnose death the body will be removed only following the permission of the SIO/DI. In these cases the body will be managed by CSI as per section 8.2.10.
10.7 Consideration must be given to the timely support of bereaved parents and the care of the deceased child, therefore families and the deceased child should be taken to an appropriate health setting, preferably ED.
10.8 Anything suspicious should be reported directly to both the police and the receiving doctor at the hospital.
10.9 Ambulance staff should pass on all the information including history, observations of the scene and resuscitation to the receiving doctor. Any other information gathered (e.g. background history, living accommodation, comments by those at the scene) should be passed on to the ED receiving doctor and the police.
10.10 It should be remembered that in most cases of infant deaths the cause of death is natural and there is little evidential benefit for delaying the removal of the body from the scene. 
10.11 Ambulance staff must notify the NWAS Safeguarding team of all sudden child deaths as per their SUDC Procedure.

11. The Hospital Staff

11.1

Unexpected Death of a Child in the ED

  11.1.1 The guidance in this section is in line with the Standards for Children and Young People in Emergency Care Settings (2012).
  11.1.2

As soon as the Emergency Department is notified that the Ambulance crew is attending the scene of a possible child death the ED nurse in-charge must notify:

  • The on-call Paediatric/resuscitation team;
  • The on-call consultant paediatrician;
  • The on-call Emergency Department consultant.
  11.1.3 In circumstances when a child is deceased at the scene consideration must be given to the timely support of bereaved parents and the care of the deceased child.
  11.1.4 If there is any doubt about the duration of the collapse, full resuscitation must be commenced and should continue according to UK Resuscitation Guidelines (2010).
  11.1.5 Clear documentation of the full resuscitation process and all investigations undertaken is essential.
11.2

Another ED nurse should be assigned to receive and support the parents through the process. The Nurse will have the following responsibilities:

  • Organising the communication process with the parents and be present throughout the process of information gathering and sharing. Bereavement support should be considered, to include bereavement counsellor, hospital chaplain, other faith leader and/or offer to contact friends and relatives;
  • Arranging parental contact with the senior paediatrician after the resuscitation has been discontinued;
  • Support the parents whilst they hold their child and it is Best Practice to remain present in the room at all times. In most situations the parents will have already handled their child after death, and allowing them to hold their child will not in any way interfere with the investigation into the cause of death. Please consider and be mindful of the environment that the deceased child and family are placed in (best practice is to avoid noisy bustling areas);
  • Will ensure that the appropriate documentation and notification processes are completed;
  • Will work closely with the Consultant Paediatrician/ED Consultant and the police to ensure that all evidence is preserved, subject to presentation of life of the child;
  • Mementoes and keepsakes should be discussed with the family and obtained and presented at their request.

If it is unclear whether the death is expected or unexpected (please see the definition of an unexpected death) the SUDC Nurse should be contacted for further advice.

11.3 To identify the possible cause of death a detailed history should be obtained. The comments of carer/parents must be recorded at all stages by a health professional in detail (and if possible verbatim) in case of future discrepancies or if suspicious circumstances develop. This history should be shared with the SUDC Nurse and SIO on their arrival to the A & E department. 
11.4

Examination should start as resuscitation commences.

  • The hospital documentation should be completed. Completion of the SUDC History Record or your own Trust's pro forma will be helpful;
  • Sites of medical lines must be marked. The site and route of any intervention e.g. venepuncture, failed cannulation, intraosseous needle, should be documented on the body chart;
  • An endotracheal tube can be removed altogether (if the death is not suspicious). Wherever possible a consultant, independent of any resuscitation attempt, establishes the correct placement of the tube and documents the same in the notes. If the endotracheal tube is found to have been inserted incorrectly, the fact must be noted and the tube left in place. If this check is not possible ensure it is clearly documented why.;
  • A full general examination of the body should be undertaken by the Consultant Paediatrician/ Emergency Consultant noting any rashes, injuries on the child, state of any clothing or bed linen.
  11.4.1 All items of clothes/bedding must be retained for subsequent examination. They may not be returned without prior consultation with the SIO and the Coroner.
  11.4.2 Before death is pronounced, blood and urine and CSF specimens can be taken for microbiology, virology, toxicology and metabolic work-up. The SIO, SUDC nurse, the Pathologist and the Coroner must be informed of what is available. Before death is pronounced, blood and urine and CSF specimens can be taken for microbiology, virology, toxicology and metabolic work-up. The SIO, SUDC nurse, the Pathologist and the Coroner must be informed of what is available.
  11.4.3 Records must accurately document which tests have been obtained. 
  11.4.4 The Consultant Paediatrician must ensure that all results of pre-mortem tests are forwarded to the Coroner and the Pathologist.
11.5 If the child is dead on arrival at hospital or when death is certified, the attending doctor should speak to the SIO.
  11.5.1 A senior nurse should check that the police have been notified.
  11.5.2 A skeletal survey will be carried out at post mortem and will be the normal method to establish skeletal fractures. However, if there are circumstances where an immediate x-ray examination is likely to add further information to the evidence, this should be discussed with the SIO and the radiologist.
  11.5.3 Notes of previous hospital, obstetric, emergency department attendances must be obtained where these notes are held at the hospital (or Trust) where the death of the infant or child is certified, the hospital staff should create these and pass them to the SIO/SUDC Nurse and/or the Coroner's officer. Where the notes may be relevant but held at another Trust, the SIO or Coroner's officer will arrange for the notes to be collected.
  11.5.4 A Check should be made to ascertain whether the child, or any sibling, is subject to a child protection plan or is/has been known to Children's Social Care. See Section 9, Children's Social Care.
  11.5.5 Other professionals also need to be informed. This should be done in consultation with your NHS Trust checklist. Paediatric Liaison should have a sharing of information form which is used to document which health professionals have been informed and the relevant date and time. This form should be signed and a copy sent to the appropriate Health Visitor/School Nurse.
  11.5.6 The parents/carers will need time to accept the information. Staff should be prepared for a range of reactions from the bereaved individuals.
  11.5.7 The family should be informed of the Rapid Response process and that a team of professionals will be involved to help understand 'why' their child has died. An explanation should be given as to why the Coroner must be informed and that a post-mortem will probably be necessary to try to ascertain the cause of death. It must also be explained that a paediatric post-mortem will always involve the taking of tissue samples for histological examination. Such an investigation does not require the consent of the parents and is a decision for the Coroner.
  11.5.8 A record should be made for every stage of contact with the family. This should include which health professionals were present for each contact. Careful documentation is required to include the full history, any verbatim comments and demeanour of the parents/carers.
  11.5.9 A member of staff should accompany the child to the mortuary once permission is given from the SIO. The child should not be left unattended. If there is to be a post mortem, then the child's body must remain in the hospital mortuary until that time.
  11.5.10 Following the Multi Agency Discussion, the SUDC Nurse will liaise with the General Practitioner and other relevant health professionals to decide on appropriate follow-up for the family.

11.6

Unexpected death of a child in a ward

  11.6.1 When a child is found collapsed, the Resuscitation Team will be called and full resuscitation carried out.
  11.6.2 When death is pronounced and is unexpected follow the SUDC Protocol, if in doubt contact the SUDC Nurse, the family will be supported by a senior member of staff. 
  11.6.3 The Senior Nurse on duty will follow the SUDC Protocol (see Recommended Sequence of Events for Rapid Response Process flow chart).
  11.6.4 The location of where the child collapsed should be treated as a scene and preserved accordingly. This includes any medical equipment being used by the child. 
  11.6.5 All information will be recorded as documented above.
  11.6.6 Staff should be offered support and debriefing as appropriate.
  11.6.7 If the child unexpectedly (as defined above) and is not a Coronial case, the Rapid Response should still be initiated. Consideration should be given to children with life limiting conditions as their death may still be unexpected

11.7

Deaths of Babies Never Discharged From Hospital

  11.7.1 See Deaths of infants never discharged from hospital.


12. The General Practitioner (GP)

The General Practitioner may be called to the scene first, and in such cases should follow the SUDC Protocol (see Recommended Sequence of Events for Rapid Response Process).
12.1 They should be aware that later they may be required to inform the police of any history obtained surrounding the death and to have noted the position of the child and the clothing at the time of their arrival.
12.2 The GP should not assume that death has occurred. If the infant, child or young person shows any signs of life, if there is any doubt about whether death has occurred, or where it is deemed that resuscitation is indicated, this should be commenced and the infant, child or young person should immediately be taken to the nearest ED by ambulance.
12.3 If there are no signs of life the GP will confirm death and call for an Ambulance, police and SUDC Nurse and notify the Coroner. The GP will inform the ED Consultant/Paediatrician on call at the hospital to which the child will be taken.
12.4 The GP will provide information for the Rapid Response process, including information sharing, involvement in multi-agency discussions and in conjunction with other health professionals, will be involved in providing ongoing advice and support for the family.
  12.4.1 If the GP was not involved with the child at the time of the death, the family GP still has a responsibility to contribute to the Rapid Response process as necessary. It is particularly important that the GP contributes to the End of Case Discussion Meeting to ensure that the bereavement needs of the family are met and that lessons are learnt where appropriate.
12.5 NB Consideration must always be given as to whether the death is expected or unexpected; if in doubt the SUDC Nurse should be contacted.


13. Community Health Professionals

13.1 The Community Health Professional may be first on the scene, and in such cases should follow the SUDC Protocol. They should be aware that later they may be required to inform the police of any history obtained surrounding the death and to have noted the position of the child and the clothing at the time of their arrival.
13.2 The gathering of relevant information from the health visitor, community practitioners, school nurse & community nurse when a sudden unexpected child death occurs is needed to aid the investigative process of the Rapid Response and the Coronial Enquiry. Whilst sharing this essential information, the need to support the professional involved with the family prior to the death of the child, must be recognised.
13.3 The SUDC Nurse will contact the Named Nurse/Safeguarding Team with the information of the child's name, date of birth, address, GP and the time of death, and will gather any other additional information.
13.4 The SUDC Nurse will contact the health visitor, school nurse and any other health professional including CAMHS, to ascertain whether there have been any professional concerns regarding the health and parenting of the child.
13.5 The SUDC Nurse will share the information with the relevant professionals involved in the Rapid Response Process.
13.6 All health Professionals should follow their own individual Trusts protocol when notified of a child death.
13.7 The Health Visitor will inform the Child Health Department to avoid further appointments being sent.
13.8 The community health professionals will ensure that all known agencies working with the child have been informed of the child's death e.g., Childrens Therapy and Nursing Services, audiology, midwifery services, community paediatricians, children’s centre’s etc. to avoid appointments being sent.
13.9 If a Police statement is required the Community Health Professional should seek support from their line manager and Safeguarding Team.
13.10 The most appropriate Health Professional will immediately offer support to the family. They will ensure that the parents are aware of how to access relevant counselling and bereavement support, and make any referrals as appropriate. The Health Professional should identify any medical or social needs and arrange support as necessary.
13.11 In case of an infant death, the parents shall be offered support with subsequent babies via the Care Of the Next Infant (CONI) scheme. The scheme should also be offered where the deceased infant was one of a multiple birth.


14. Midwife

14.1 These guidelines inform midwives of the procedures in the event of unexpected death of a child and excludes babies who are stillborn and planned terminations of pregnancy carried out within the law.

14.2

If the community midwife is first on the scene 

  14.2.1 The community midwife should not assume that death has occurred. If the child shows any signs of life or where it is deemed that resuscitation is indicated, this should be commenced, paramedics notified, and the child should immediately be taken by ambulance to the nearest ED. Mother’s medical condition must also be assessed immediately and appropriate emergency treatment sought.  If the mother’s condition requires obstetric intervention, she should be transferred with a midwife to the nearest appropriate maternity unit, whether she is booked there or not.
  14.2.2 If the indications are that the baby is dead and no active resuscitation has been attempted, the body and placenta should remain in situ. The midwife must inform the emergency services and their supervisor of midwives.
  14.2.3 The position of the baby and the condition in which it was found must be documented together with any comments/explanations of the mother or any other person at the scene. Try not to disturb the scene, i.e. do not touch or move anything.
  14.2.4 When the paramedics arrive, spend time listening to the parents and offer support.
  14.2.5 If the mother is alone, ensure that she has the appropriate family support.
  14.2.6 If the baby is not resuscitated the body will be taken to a hospital ED in line with section 8.2.10.
  14.2.7 If the midwife has any relevant information about the pregnancy or the family, this should be reported directly to the police and ED staff as soon as possible.
  14.2.8

Records should be written up immediately making particular reference to:

  • Any inappropriate delay in seeking help;
  • The position of the baby and the condition in which it was found;
  • Inconsistent explanations - accounts should be recorded verbatim in quotes;
  • Evidence of drugs/alcohol abuse;
  • Parents reaction/demeanour;
  • Unexplained injury e.g. Bruises, burns, bites, presence of blood;
  • Neglect issues;
  • Position of where the baby was found and its surroundings;
  • General condition of the accommodation;
  • Evidence of high risk behaviour e.g. Domestic violence.
14.3

Mother and baby's records will be secured immediately by the Police or the Coroner's Officer as soon as the death has been notified. A copy will be made available for the midwives. This is a precautionary measure until the situation is clarified.

  14.3.1 The family G.P. and health visitor must be informed as soon as possible.
  14.3.2 In the case of a death on the maternity unit, also contact: Supervisor of Midwives, co-ordinator on delivery suite and Head of Midwifery. The SUDC Protocol needs to be initiated.
  14.3.3 Consideration needs to be given to the retention of the placenta.

14.4

If you learn later that a baby has died

  14.4.1 Contact the SUDC nurse and ensure that the following agencies/professionals are informed of the infant's death:
  • Medical records department/maternity/children's hospitals;
  • Child health department to avoid appointments/reminders being sent;
  • The family G.P. in case she/he has not already been contacted by the police/hospital;
  • Health visitor;
  • Audiology department if the infant has been referred for follow-up or has not yet had neonatal screening;
  • Named Nurse for Safeguarding Children and the relevant line manager;
  • School Nurse if there are older siblings in the family;
  • Any other department to which the infant has been referred/seen if follow-up appointments are possible, e.g. Sure Start, Social Care.
  14.4.2 Discuss the support the parents/carers/extended family require.
  14.4.3 If the mother was breast feeding, discuss and advise on the suppression of lactation and give appropriate support. Refer to the GP if necessary.
  14.4.4 The midwife will ensure that the midwifery records are available to the SUDC Nurse and be available to attend any subsequent multi-agency meeting. If still visiting the mother photocopy the hand held records and take to the meeting.
  14.4.5 The midwife will be prepared to provide a Statement of Evidence if requested and seek advice from your line manager, supervisor, union and Safeguarding Team.

14.5

The next pregnancy:

  14.5.1 Ensure that the C.O.N.I. co-ordinator has been notified as soon as possible.
  14.5.2 The midwife will scrutinise previous records to ascertain whether it is necessary to inform any other professional/agency of the pregnancy e.g. Social Worker.
  14.5.3 The midwife will ensure that any previous infant death is highlighted in the maternity records.
  14.5.4 The midwife will ensure that the family receives appropriate support during the pregnancy, delivery, and post-natal period.

14.6

Deaths of infants never discharged from hospital

  14.6.1

All deaths of newborn infants that occur in hospital must be considered, in context with the circumstances of the birth and any history available. Enquiries must be made to identify any concerns regarding the mother or the family:

  • If a baby dies due during a birth and there is a clear medical explanation for the death which is a natural disease process running its full course, this should not be treated as an unexpected death. However, if there are any circumstances that have caused the death to be in some way unnatural or intervention that has shortened the life of the child advice should be sought from the Coroner;
  • If a baby dies in the same circumstances (i.e. whilst under medical supervision), with no immediate medical explanation apparent for the child's death, this is a death of 'cause unknown' and should be referred to the coroner unless a doctor who attended the deceased child in their last illness, assuming the child showed some signs of life, can issue a Medical Certificate of Cause of Death (MCCD).
  14.6.2 Further enquiries must be made to identify any concerns regarding the mother or the family.
  14.6.3 After all relevant considerations have been made, if the death is deemed unexpected, then the SUDC Protocol and Rapid Response process MUST be initiated, and internal reporting mechanism complied with.


15. The Coroner and Pathologist

15.1 After death is confirmed, the Coroner has control of the body.
15.2 In all cases of SUDC of age <2 years a full skeletal survey will be taken at the time of the post mortem.
15.3 In most cases of SUDC, the post-mortem will be performed by a Paediatric Pathologist. In older children and adolescents with road traffic accidents, hangings, drug overdoses, the post mortem may be carried out by a general pathologist at the direction of the Coroner. If there are suspicious circumstances a Home Office Pathologist will take the lead role in the post-mortem again at the direction of the Coroner. It is recommended that each Pathologist produce a separate report.
  15.3.1 Before the Post Mortem commences the Pathologist must have written authority from the Coroner.
15.4 The SIO and SUDC Nurse is responsible for ensuring that the Coroner and Pathologist are provided with the summary, of the full medical history including any relevant background information concerning the family and any concerns raised by any other agency. The SUDC Nurse will also provide a written report for the Pathologist at time of post mortem and the Coroner within 28 days.
15.5

A clear high resolution copy of the following documents should accompany the body to the mortuary:

  • Hospital case records;
  • Ambulance notes;
  • ED Notes;
  • Obstetric/delivery notes of the mother if the child is less than 3 months old;
  • Report of the police scene;
  • G72.
15.6 The hospital must ensure that all pre mortem blood samples are preserved and that the results of pre-mortem samples are forwarded to the Coroner and the Pathologist.
15.7 If the post mortem is a home office post mortem, the SIO must ensure that all relevant professionals who have notified the Coroner that they wish to attend the post mortem and any other persons entitled to be represented by a medical practitioner, are informed of the time and place of the post-mortem. If the post mortem is a paediatric post mortem, this role is performed by the Coroner's officer.
15.8

The post-mortem examination shall be carried out promptly. All persons involved with these guidelines will co-operate to ensure this happens. A full post-mortem report shall be provided in writing to the Coroner as soon as possible. All investigations are to be concluded within the shortest possible time, to enable:

  • The prompt funeral of the child;
  • The expeditious conclusion of the inquest into the death of the child.
15.9 In the event of a suspicious death the SIO/Investigating Officer (or appointed representative) and the Scene Crime Officer must attend the post-mortem.
15.10 If the Paediatric Pathologist carrying out the post-mortem examination wishes to retain a whole organ (solely for the purpose of establishing the cause of death) he/she will notify the Coroner. The Coroner, through his officer, will enquire of the family as to their wishes as to the ultimate disposal of the organ so retained and whether or not this is to occur with the body.
15.11 All non-PACE samples taken at post-mortem are under the control of the Coroner and must be labelled, identified and dealt with in accordance with the Coroner's instructions and the Human Tissue Act 2004.
15.12 The interim results of any post-mortem will be communicated immediately to the Coroner on the relevant form. Bearing in mind possible legal implications arising from the findings, the Coroner will use his discretion as to what information will be passed to the lead Paediatric Consultant. The Coroner will endeavour to be as helpful as possible with the provision of information. The Paediatrician may be instructed to keep some information strictly confidential.
15.13

After the post mortem, and in any event within 48 hours of the post-mortem, the Pathologist will provide to the Coroner in writing the following information:

  • The preliminary post-mortem pathological findings (if any);
  • The preliminary cause of death if ascertained;
  • Details of tissues retained for further examination (if any).
  15.13.1 The Coroner will brief his staff within 72 hours of the death with the information appropriate to share with other agencies who telephone the Coroner's office requesting the information. Those receiving such information will treat the same with confidentiality.
15.14 On receipt of the interim post-mortem result the SIO/SUDC Nurse will arrange any further discussions.
15.15 The final written post-mortem report should be made available within 14 days of the conclusions of investigations, a list of samples taken, whether these were taken under Coronial authority or seized by the police under PACE and the results of subsequent tests.
15.16 Upon receipt of a written post mortem report the Coroner will provide a copy to the SUDC Nurse, Paediatrician and the SIO as per local arrangements. However, this is always subject to the Coroner's judicial discretion and it is expected that it will only be in very rare cases the Coroner will decline and will explain his reason in writing for taking such a course of action. The copy of the post mortem report will be shared directly with the SUDC Nurse or with the CDOP Coordinator who will forward a copy to SUDC Nurse. This will initiate the planning of an End of Case Discussion meeting and unless otherwise notified by the Coroner the SUDC Nurse will assume permission from the Coroner to hold such a meeting.
15.17 There is within these guidelines agreement for the collection of medical samples, radiological examination and care of intravascular and surgical lines. This must be followed and any proposed deviation discussed with the Coroner.
15.18 A Coroner's post-mortem is not subject to consent and takes place irrespective of the parents' wishes. The Pathologist will inform the Coroner about the tissue samples taken during the post mortem and whether or not these are taken under the Coroner's authority (and subject to the Human Tissue Act 2004) or have been seized by the police under PACE. Thereafter the Coroner's officers will consult with the family as to the ultimate disposition of those samples taken under the Coroners authority, the choices being for the tissues to be preserved as part of the permanent medical record, returned to the parents (i.e. funeral director), or respectfully disposed off. The police will comply with the requirements of PACE but no samples will be disposed of until after the inquest has taken place. This should then be communicated with the Pathologist in order that the families' wishes may be carried out at conclusion of the Inquest.  


16. Parent Support and Communication

16.1 An unexpected death of a child is perhaps the most devastating trauma and grief that any person can sustain. The parents go through different emotions ranging from shock, disbelief, guilt and anger. There is added stress posed by police investigations and pending post mortem and the inquest. While the professionals are geared to the procedures and the guidelines for dealing with sudden unexpected death of a child, for parents it is most likely the first and the only life-time tragic experience and each component of this experience is very traumatic. Any minor aberrations or deviations of the observed process add to this trauma. Hence it is of paramount importance that the professionals dealing with SUDC are fully aware of the SUDC Protocol. Experience shows that if families are supported appropriately in the earliest stages of grief and trauma, the long term detrimental effects of losing a child can be lessened.
16.2 Professionals and the parents/carers meet at certain strategic points and these need to be kept within strict professional boundaries. All professionals should maintain contact with each other to ensure that the support for the family remains in place as appropriate. 
16.3 There is no place for personal views, opinions and interpretations and only factual information should be shared.
16.4 The first direct contact is likely to be with the ambulance staff. The staff, while supporting parents, can explain the factual condition of the child to the parents, the procedures being undertaken (CPR, Oxygen etc.) and the transportation process.
16.5 As soon as the ED department receives the notification of an arrival a senior nurse should be assigned to receive and support the parents, as discussed on The Hospital Staff.  
16.6 Repeated questioning of the parent/guardian/carer, by different health professionals and police officers MUST be avoided. There must be a co-ordinated approach between all relevant professionals to obtaining information from the family.
16.7

Before leaving the department, the nurse will:

  • Ensure that parents receive an explanation and are given leaflets about the:
  • SUDC procedure;
  • Bereavement and counselling support;
  • National Parent Support groups e.g. Lullaby Trust, Winston's Wish, Child Bereavement Charity etc.
  16.7.1 Mementoes and keepsakes should be discussed with the family and obtained and presented at their request with prior consent from the SIO.
16.8 Of great concern to the family is where the child will be kept and when he or she will be released for burial or cremation. Any discussion regarding such information is to be relayed via the Coroner's officer.
  16.8.1 It is important to be aware of religious and cultural issues at the time of the infant/child's death. Sometimes a blessing may be requested and this should be supported where possible in an appropriate environment. Family's wishes may not always be possible to be accommodated due to coroner's jurisdiction.


17. Information Sharing

17.1 Section 10 Children Act 2004: statutory guidance states that good information sharing is key to successful collaborative working and that arrangements under s10 CA 2004 should ensure that information is shared for strategic planning purposes and to support effective service delivery.
17.2 Section 11 Children Act 2004: places a duty of bodies within the NHS to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children.
17.3 Chapter 5 of Working Together to Safeguard Children (2015) sets out the regulations relating to child deaths review functions and this includes collecting and analysing information about each death.
17.4 Having expressed or implied powers does not mean that the Human Rights Act 1998, the Common Law Duty on Confidentiality and the Data Protection Act 1998 can be disregarded.
17.5 Human Rights Act 1998: Article 8. 2: the right to respect for private and family can be legitimately interfered with where it 'is in accordance with the law and is necessary... in the interests of... protection of health and morals or the protection of rights and freedoms of others.
17.6 The sharing of information within the Child Death Overview Processes is a function set out in regulation 6 under s. 13 Children's Act 2004 and therefore is in accordance with the law. It can be seen as a proportionate response in relation to the pressing social need for the protection of health and morals or the protection of rights and freedom of others.
17.7 Common Law Duty of Confidentiality: The common law provides that where there is a confidential relationship, the person receiving the confidential information is under a duty not to pass on the information to a third party. The duty is not absolute and can be shared without breaching the common law duty if there is an overriding public interest in disclosure.
17.8 Data Protection Act 1998: Information sharing within the Child Death Overview Processes is a statutory function and the Data Protection Act therefore permits the sharing of information without express consent of the subjects.
17.9 0 - 18 years Guidance for all Doctors: General Medical Council (GMC) 2007 para 47 - 50: discusses how Doctors can disclose information without consent if it is in the public interest to do so.


18. Definitions/Glossary

Age For the purpose of this Protocol a child is defined as a child or young person from birth (excluding both those babies who are stillborn and planned terminations of pregnancy carried out within the law) up to the age of 18 years.
ALTE Apparent Life Threatening Event.
Apnoea Absence of breathing.
Care of Next Infant (CONI) A national Health Visitor led service for bereaved parents who have suffered a sudden and unexpected death of a baby. The programme supports families before and after the birth of their next baby. CONI is run in hospitals and community health centres and involves health visitors, midwives, paediatricians and GPs.
Child Death Overview Panel (CDOP)  This is a multi professional group which has a permanent core membership drawn from key organisations represented by the Local Safeguarding Children Board (LSCB). The function of CDOP is to review the available information on all child deaths up to 18 years whether expected or unexpected in the LSCB area to identify themes and trends. 
Clinical Commissioning Groups  These groups are a core part of government reforms to the health and social care system. In April 2013 they replaced primary care trusts (PCT's) as the commissioners of most services funded by the NHS in England. They now control almost 2/3 of the NHS budget and have a legal duty to support quality improvement in general practice. 
Coronial Inquiry/ Inquest  A Coroner is an independent judicial officer who investigates deaths of unknown cause, violent or accidental deaths or deaths while a person is detained are reported to the Coroner. A coroner's jurisdiction over a body (i.e. which coroner will deal with a death) is determined by where the body is located, although deaths can be transferred between coroners. A Coroner may conduct preliminary enquiries, which may or may not include a post mortem of various types, may also conduct an investigation to further investigate the death which may or may not culminate in an inquest. At an inquest the Coroner is required to answer, so far as the evidence allows, who has died, where and when the death occurred and by what means a person came by their death. 
CPR  Cardio-pulmonary resuscitation. 
Emergency Department Preferred name of an Accident and Emergency (A&E) Department.
Forensic Pathologist Home Office Pathologist (see below).
Frenulum A fold of membrane that limits the movement of an organ. In these circumstances it means the upper lip unless otherwise specified. It may also be applied to the tongue or foreskin of the penis.
Home Office Pathologist A pathologist with special training as a forensic pathologist who is on the Home Office list of accredited forensic pathologists.
Community Health Professional  Any health professionals based within the community e.g. community practitioner, health visitor, school nurse or community nurse.
Infant For the purposes of this document, the medical definition of infant is used. An individual of less than 2 years of age, rather than the legal definition of infant as an individual under the age of 18 years.
Lancashire  Use of the term 'Lancashire' refers to the geographical region as opposed to specific LSCB area.
LSCB (Local Safeguarding Children Board) The LSCB is the key statutory mechanism for agreeing how the relevant organisations in each local area will co-operate to safeguard and promote the welfare of children in that locality in addition to ensuring the effectiveness of what they do.
NHS England  Their function is to improve health outcomes for people residing in England.
Personal child health record  Also known as Red Book. This is a child's personal health record. It is the main record of a child's health, growth and development. It is given prior to discharge from hospital to a mother following the birth of her baby. 
Petechial Haemorrhages A Petechia(e) is a small red or purple spot on the body caused by a minor haemorrhage (broken capillary blood vessels).
Police Protection Power (PPP) Previously known as Police Protection Order (PPO).
Post Mortem/Home Office Post Mortem A post-mortem (autopsy) is an examination of a body after death. They are carried out by a pathologist to establish the cause of death. A pathologist is a doctor who specialises in understanding the nature and cause of disease.
PPU (Public Protection Unit) An area of policing that deals with family matters.
Retinal Haemorrhage Bleeding which occurs in the retina, on the back wall of the eye. This can occur as a result of a medical condition or as a result of shaking, particularly in young babies or a severe blow to the head.
Senior Investigating Officer (SIO) A police officer who is accredited to manage the investigation into sudden/ suspicious deaths. It is recommended that the police officer attending should be a detective of at least Inspector rank (ACPO Crime Committee, 2000).
Serious Case Review The purpose of a serious case review is to establish lessons that may be learned from a case about the way local professionals and organisations have worked together and individually to safeguard and promote the welfare of children. In addition to identifying what those lessons are both within and between agencies, how and within what timescales they will be acted upon and what is expected to change as a result. Another function is to improve intra and inter-agency working and to better safeguard and promote the welfare of children.
Skeletal Survey A skeletal survey is a series of X-rays of all the bones in the body.
Subdural Haemorrhage A subdural haematoma or haemorrhage is a type of blood clot usually associated with traumatic brain injury.
SUDC Sudden Unexpected Death in Childhood.
SUDC Nurse A Specialist Nurse which provides expert health input into the Rapid Response investigation, and where deemed appropriate will lead the multiagency response to an infant or child death.
Suspicious circumstances Factors in the environment, history or examination that may give rise to concern about the circumstances surrounding the death.
Unexpected death The death of a child that was not anticipated as a significant possibility, for example 24 hours before the death or where there was a similarly unexpected collapse leading or precipitating events which led to the death.


19. References

19.1 Children Act (2004).
19.2 Confidential Enquiry into Maternal and Child Health.
Why Children Die: A Pilot Study. NCB 2006.
19.3 Data Protection Act (1998).
19.4 Human Rights Act (1998).
19.5 0 - 18 years Guidance for all Doctors: General Medical Council (GMC) 2007.
19.6 Preventing Childhood Deaths: A study of 'Early Starter' Child Death Overview Panels in England. Department for children, schools and families. University of Warwick, 2008.
19.7 Royal College of Paediatrics and Child Health guidance on Child Death Review Process 2008.
19.8 Sudden unexpected death in infancy: A multi-agency protocol and investigation (Chair Baroness Helena Kennedy). Royal College of Paediatrics and Child Health 2004.
19.9 Working Together to Safeguard Children: A guide to interagency working to safeguard and promote welfare of children. HM Government DOH London, 2010.
19.10 Human Tissue Act (2004).


Appendix 1 - Support for Staff Following the Death of a Child

Professionals working with children and young people frequently experience difficult and challenging situations as well as hugely rewarding and empowering experiences, all of which can have a positive or negative effect their psychological and emotional wellbeing. One of the most distressing experiences professionals are likely to encounter is when a child or young person they have been working with tragically dies in unexpected circumstances.

When this happens agencies need to ensure they recognise and appreciate the impact this can have on staff and colleagues and ensure they provide appropriate support and in some cases assist people in accessing more specialist counselling or therapeutic services.

It is recognised that each agency has detailed procedures and processes to follow when a child dies to ensure its responsibilities are discharged with due diligence. However, it is also felt that the emotional impact on staff who worked with the child or family should not be overlooked or minimised in any way.

Understanding Bereavement / Loss

Bereavement affects people in different ways but experts generally accept that there are four stages of bereavement:

  • Accepting the loss is real;
  • Experiencing the pain of grief;
  • Adjusting to life without the person who has died;
  • Moving on - putting less emotional energy into grieving and putting it into something new.

Most people go through all these stages, but won't necessarily move smoothly from one to the next. Someone's grief might feel chaotic and out of control, but these feelings will eventually become less intense over time. It is normal for people to feel:

  • shock and numbness (this is usually the first reaction to the death, and people often speak of being in a daze);
  • overwhelming sadness, with lots of crying;
  • tiredness or exhaustion;
  • anger, for example towards the person who died, their illness or a/their God(s);
  • guilt or regret about not doing or saying something which could have made a difference.

The final point above will likely be the most relevant to professionals who have worked with the child or family, though they may also experience the other stages to some degree.

It is also common for people to become forgetful or distracted by their grief which can affect their ability to concentrate or work to their usual standards.

In some cases shock and denial can often delay the grieving process and it may seem that a person is coping well, often it is when things begin to get back to 'normal' that the grieving process hits.

Supporting Staff and Colleagues

Everyone is different and it needs to be recognised that what helps one person may not be as helpful to someone else. However, experts agree that the following things can all help people in dealing with grief:

  • Talking and sharing feelings with someone, such as a trusted colleague, friend or family member;
  • Acknowledging feelings without minimisation;
  • Talking about the child who has died rather than avoiding mentioning them;
  • Taking time out or some time off work;
  • Distraction - e.g. going for a walk, doing something different;
  • Remembering and talking about good memories of the child;
  • Laughter is the best medicine - try and find something to humour someone;
  • Offer practical assistance with day to day tasks which can be more difficult during a period of grief;
  • Come together as a team to talk about the child and how people are feeling;
  • Recognise that staff may still need support well beyond the initial shock and acceptance.

It should be borne in mind that support for staff or colleagues may be complicated by confidentiality procedures or legal processes which prevent the case being discussed beyond immediate colleagues.

Any group support should be lead by a suitably experienced practitioner and should concentrate on facts, feelings and the future rather than an in depth look at practice issues.

It should also be noted that a number of events following the death may trigger further distress for professionals such as any related legal proceedings, the inquest or media attention. These may potentially cause distress and increase the support needs for professionals involved in the case.

Professionals who are parents with children of a similar age or who may have had a similar personal experience may also be particularly vulnerable in these circumstances.

Further Support

In some cases staff members who have been particularly traumatised may need to be referred for more specialised bereavement counselling or therapeutic support. Many large organisations have in house support services for employees which should be accessed as appropriate. However, smaller and voluntary organisations may need to seek external services.

The following organisations all provide bereavement services in Lancashire:

Further Information:


Appendix 2 - Information Sheet: Organ Donation

Click here to view the Organ Donation Fact Sheet.


Appendix 3 - Sudden Unexpected Death in Childhood (SUDC) Full History Record

Click here to view the Sudden Unexpected Death in Childhood (SUDC) Full History Record.

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