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7.2 Rotherham Child Death Review Process Including Dealing With Unexpected Child Deaths (Rapid Response)


ACPO – A Guide to Investigating Child Deaths


In May 2015, a link was added to ACPO – A Guide to Investigating Child Deaths in the Related Guidance section.


The Regulations Relating to Child Death Reviews
Specific Responsibilities of Relevant Bodies in Relation to Child Deaths
Specific Responsibilities of Relevant Professionals when Responding Rapidly to the Unexpected Death of a Child
Child Death Review Process Definitions


  1. Each death of a child is a tragedy for his or her family (including any siblings) and enquiries should keep an appropriate balance between forensic and medical requirements and supporting the family at this difficult time;
  2. Professionals supporting parents and family members should assure them that the objective of the child death review process is not to blame anyone, but it is to learn lessons in order to improve the health, safety and well-being of children and ultimately to prevent further such child deaths;
  3. That the whole rapid response process should align with and support the Coroners investigations into the cause of a child death.

The Regulations Relating to Child Death Reviews

  1. The Rotherham LSCP functions in relation to child deaths are set out in Regulation 6 of the Local Safeguarding Children Partnerships Regulations 2006. The RLSCP is responsible for:
    1. Collecting and analysing information about each death with a view to identifying;
      • Any case giving rise to the need for a review mentioned in regulation 5(1)(e);
      • Any matters of concern affecting the safety and welfare of children in the area of the authority; and
      • Any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area; and
    2. Putting in place procedures for ensuring that there is a co-ordinated response by the authority, their Board partners and other relevant persons to an unexpected death.

Specific Responsibilities of Relevant Bodies in Relation to Child Deaths

  1. Registrars of Births and Deaths (Children & Young Persons Act 2008):
    • Supply the LSCP with information which they have about the death of the child they have registered;
    • Notify LSCPs if they issue a Certificate of No Liability to Register.

Send the information to the appropriate LSCP (the one which covers the sub-district in which the register is kept) no later than seven days from the date of registration.

  1. Coroners (Coroners Rules 1984 (as amended by the Coroners (Amendment) Rules 2008
    • Duty to inform the LSCP, for the area in which the child died, of the fact of an inquest or post mortem.

Powers to share information with LSCPs for the purposes of carrying out their functions, including reviewing child deaths and undertaking SCRs.

  1. Registrar General (section 32 of the Children and Young Persons Act 2008)

Power to share child death information with the Secretary of State, including about children who die abroad.

  1. Medical Examiners

Share information with LSCPs about child deaths that are not investigated by a coroner.

  1. Clinical Commissioning Groups

    Have arrangements in place to secure the expertise of, consultant paediatricians whose designated responsibilities are:
    • To provide advice on commissioning paediatric services from paediatricians with expertise in undertaking enquiries into unexpected deaths in childhood, and from medical investigative services; and
    • The organisation of such services.

Responsibilities of the Rotherham Local Safeguarding Children Partnership (RLSCP)

  1. The RLSCP is responsible for ensuring that a review of each death of a child who is normally resident in Rotherham is undertaken by the Rotherham Child Death Overview Panel (CDOP). A summary of the child death processes to be followed when reviewing all child deaths is set out in Flowchart 1. The processes for undertaking a rapid response when a child dies unexpectedly are set out in Flowchart 2;
  2. RLSCP should be informed of the deaths of all children normally resident in their geographical area. The RLSCP will inform the CDOP of such cases so that the deaths of these children can be reviewed.

    In cases where organisations in more than one LSCP area have known about or have had contact with the child, lead responsibility sits with the LSCP for the area in which the child was normally resident at the time of death. Rotherham LSCP and local organisations which have had involvement in the case will cooperate in jointly planning and undertaking the child death review. In the case of a Rotherham looked after child, the Rotherham LSCP will take lead responsibility for conducting the child death review wherever that child dies.

Specific Responsibilities of Relevant Professionals when Responding Rapidly to the Unexpected Death of a Child

Designated paediatrician for unexpected deaths in childhood (designated paediatrician):

  1. Ensure that relevant professionals i.e. G.P, other relevant health professionals, coroner, police and Social Care are informed of the death; initiate the co-ordination of the team of professionals (involved before and/or after the death) which is convened when a child who dies unexpectedly (accessing professionals from specialist agencies as necessary to support the core team; convene multi-agency discussions after the initial and final post mortem results are available.

Action by professionals when a child dies unexpectedly

  1. Immediate

    When a child dies suddenly and unexpectedly including from suicide or trauma the child should normally be transported by emergency ambulance to a hospital Emergency Department accepting children. Unless death has been verified at the scene resuscitation should be commenced. Only in exceptional circumstances should the Police require a child's body to remain at the place of death.

    All professionals responding to a child death must commence resuscitation measures if possible, ensure there is no risk to survivors or responders, support and care for the family, act to preserve the scene and investigate the cause of death. This assessment of risk to survivors should include other children in the household or vicinity.

    The consultant clinician (in a hospital setting) or the professional confirming the fact of death (if the child is not taken immediately to an Emergency Department) should inform the local designated paediatrician with responsibility for unexpected child deaths at the same time as informing the coroner;
  2. A paediatrician should undertake a full external examination of the body including the position of livido (this may be an Emergency Department consultant or deputy for 16-18 year old young people). Appropriate bacteriological samples should be undertaken.

    Where a death appears to be from natural causes the paediatrician should initiate an immediate information sharing and planning discussion between the involved agencies (i.e. health, police and Children's Social Care) to decide what should happen next and who will do it. Where possible ambulance first responders should be present at the immediate information sharing meeting. Where initially the death appears to be from external causes, suicide, homicide or accidents this would normally be led by the Police in conjunction with other agencies. Coroners officers will be informed of the meetings and of their findings and may attend at their discretion. The designated paediatrician or lead police officer will be responsible for formally reporting to the Coroner (Paragraph 28).
  3. Intensive life support

    Where a child is on intensive life support and is not expected to survive and where their illness or injuries were not anticipated as a significant possibility 24 hours prior to admission or there was an unexpected collapse or incident leading to or precipitating the events which led to the admission. prior to their life support, then rapid response may be initiated prior to death.
  4. Care of the family

    Bereaved families need care and support and should be at the centre of all agencies concerns. Care does not impede investigation. Parents should be allowed to touch or hold their child if they wish. Care and support facilitates trust and investigation of the cause of death. Good support and communication is an essential part of the investigation.
  5. Scene Preservation

    Information, observation and whole scene preservation of the place of death are key. This should be discreet, parents need not be excluded from a child's room and routine seizure of items from a room has little evidential value and is particularly distressing for parents.

    Videos or photographs are the responsibility of the police or forensic investigator.
  6. Possible causes for concern

    May include:
    • Delays in seeking help;
    • Inconsistency in history or findings;
    • Findings not in keeping with a child's age and abilities;
    • Child known to be at risk (subject to a plan);
    • Impaired mental health of close relative including significant learning disabilities;
    • Evidence of domestic violence;
    • Inappropriate aggressive or unexpectedly co-operative behaviour;
    • Extreme squalor;
    • Evidence of substance misuse (alcohol);
    • Dangerous sleeping environment;
    • Inappropriate toys, food, bedding;
    • Writing, diaries, computer.

Responding to concerns is the responsibility of the Police.

Including forensic investigation, securing evidence and appropriate interviews.

The great majority of unexpected deaths of children are NOT suspicious.

  1. The joint responsibilities of all the professionals involved

    These include:
    • Responding quickly to the child's death;
    • Making immediate enquiries into and evaluating the reasons for and circumstances of the death, in agreement with the coroner;
    • Liaising with the coroner and the pathologist;
    • Undertaking the types of enquiries/investigations that relate to the current responsibilities of their respective organisations;
    • Collecting information about the death (the templates (Forms A-C) for recording information about each child's death that can be accessed at: the Department for Education website or from the Rotherham CDOP Office;
    • Providing support to the bereaved family and relevant others, referring to specialist bereavement services where necessary and keeping them up to date with information about the child's death.
  2. If the child dies suddenly or unexpectedly at home or in the community, the child should normally be taken to an Emergency Department rather than a mortuary. This facilitates examination, sample taking and family support. In some cases when a child dies at home or in the community, the police may decide that it is not appropriate to move the child's body, for example because forensic examinations are needed;
  3. As soon as possible after arrival at a hospital, the child should be examined by a consultant paediatrician or paediatric registrar (this may be an Emergency Department consultant or deputy for 16-18 year old young people) and a detailed history should be taken from the parents or carers. The purpose of obtaining this information is to understand the cause of death and identify anything suspicious about it. In all cases when a child dies in hospital, or is taken to hospital after dying, the hospital should allocate a member of staff to remain with the parents and support them through the process;
  4. If the child has died at home or in the community, the senior investigating police officer and the designated paediatrician should decide whether there should be a visit to the place where the child died, how soon (normally within 24 hours) and whether it is appropriate for any other professionals to be in attendance. This should almost always take place for cases of sudden infant death*. After this visit the senior investigating police officer, designated paediatrician, GP, health visitor or school nurse and Children's Social Care representative should consider whether there is any information that raises concerns that neglect or abuse was a contributing factor in the child's death;
  5. Registered providers of healthcare services must notify the Care Quality Commission of the death [regulation 16 of the Care Quality Commission (Registration) Regulations 2009]. Where a young person dies at work, the Health and Safety Executive should be informed. Local Management reviews undertaken by Youth Offending teams should also feed into the CDOP child death processes;
  6. If there is a criminal investigation, the team of professionals must consult the Senior Investigating Officer and the Crown Prosecution Service to ensure that their enquiries do not prejudice any criminal proceedings. If the child dies in custody, there will be an investigation by the Prisons and Probation Ombudsman (or by the Independent Police Complaints Commission in the case of police custody). Organisations who worked with the child will be required to cooperate with that investigation.

Involvement of the Coroner and pathologist

  1. If a doctor is not able to issue a medical certificate of the cause of death, the lead professional must report the child's death to the coroner. The coroner will then have jurisdiction over the child's body;
  2. The coroner will order a post mortem by a pathologist. The designated paediatrician will collate and share information about the circumstances of the child's death with the pathologist in order to inform this process;
  3. If the Coroner's investigation or a post mortem reveal that the death was due to natural causes and that an inquest is not needed, the Coroner will release the body and the relatives can register the death. The funeral can then take place. If an inquest is to be held a death cannot be registered until it has been completed, but the Coroner will usually issue a certificate that will allow the funeral to take place If a death has been referred to the Coroner a Registrar cannot register the death and issue a Death Certificate until the body is released by the Coroner;
  4. If the death is unnatural or the cause of death cannot be confirmed, the coroner will hold an inquest. Professionals and organisations who are involved in the child death review process will co-operate with the coroner and provide him/her with a joint report about the circumstances of the child's death. This report should include a review of all medical, Social Care and educational records on the child. The report should be delivered to the coroner within 28 days of the death unless crucial information is not yet available.

Action after the post mortem

  1. The results of the post mortem belong to the Coroner. By agreement in Rotherham these are shared with the designated paediatrician and the senior investigating officer, to discuss the findings as soon as possible with the pathologist. The Coroner will be informed immediately of the initial results of these discussions. If these results suggest evidence of abuse or neglect as a possible cause of death, the paediatrician should inform the police and Children's Social Care services immediately. He or she should also inform the RLSCP Chair and Business Manager so that they can consider the case against Serious Case Review criteria;
  2. Following the initial post-mortem, an officer from the Safeguarding Children Unit, or other named Safeguarding Children lead, should liaise with the Designated Paediatrician, coroner via South Yorkshire Police, and other relevant agencies that knew the child or family and/or are involved in investigating the death. This will usually culminate in a multi-agency meeting (held a maximum of 10 days after the initial post-mortem findings), the purpose of which is to:
    • Share information;
    • Review further information which may raise additional concerns about Safeguarding Children issues. This may lead to the need for a strategy meeting and further investigation; or will require consideration against Serious Case Review criteria;
    • Plan appropriate support for family members;
    • Identify any initial lessons from agency responses to the death.
  3. The professionals should review any further available information, including any that may raise concerns about safeguarding issues. A further multi-agency case discussion (normally 8-10 weeks after the death) should be convened and led by the designated paediatrician as soon as the final post mortem result is available. This is in order to share information about the cause of death or factors that may have contributed to the death and to plan future care of the family. The designated paediatrician should arrange for a record of the discussion to be sent to the coroner, to inform the inquest and cause of death, and to the Child Death Overview Panel, to inform the child death review.
  4. Responsibilities of the Rotherham Child Death Overview Panel

    The CDOP is responsible for:
    • Reviewing all child deaths up to the age of 18, excluding both those babies who are stillborn and planned terminations of pregnancy carried out within the law;
    • Collecting and collating information on each child and seeking relevant information from professionals and family members. Templates (Forms A-C) for recording information about each child's death can be accessed at: the Department for Education website);
    • Discussing each child's case, and agreeing who will provide feedback to the family, in an appropriate and timely manner;
    • Determining whether the death was deemed preventable and decide what, if any, actions could be taken to prevent future such deaths;
    • Making recommendations to the RLSCP or other relevant bodies promptly so that action can be taken to prevent future such deaths where possible;
    • Identifying patterns or trends in local data and reporting these to the RLSCP; and
    • Where a suspicion arises that neglect or abuse may have been a factor in the child's death, referring a case back to the RLSCP Chair for consideration of whether an SCR is required.
  5. The aggregated findings from all child deaths should inform local strategic planning, including the local Joint Strategic Needs Assessment, on how to best safeguard and promote the welfare of children in their area. The Rotherham CDOP will an annual report of relevant information for the RLSCP. This information should inform the RLSCP annual report.

Child Death Review Process Definitions

Unexpected death of a child:

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 led to the death.

The designated paediatrician responsible for unexpected deaths in childhood should be consulted where professionals are uncertain about whether the death is unexpected. If in doubt, the processes for unexpected child deaths should be followed until the available evidence enables a different decision to be made.

Preventable child deaths:

Those in which modifiable factors may have contributed to the death. These factors are defined as those which, by means of nationally or locally achievable interventions, could be modified to reduce the risk of future child deaths.

In reviewing the death of each child, the CDOP should consider modifiable factors, for example in the family and environment, parenting capacity or service provision, and consider what action could be taken locally and what action could be taken at a regional or national level.