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4.1 Responding to Child Death


Child Death Overview Panel Procedure

See also Learning and Improvement Framework Procedure


This chapter was amended in October 2013. Section 3, The Three Phases within the SUDIC Response Process (SRP) Phase 1: Initial enquiries has been revised to reflect that during office hours the CDR Manager is responsible for co-ordinating the multi-agency response. Section 4, Practical Procedures for implementing the SUDIC Response Process (SRP), Joint Visit has been amended and should be re-read. Appendix 1: Responding to Sudden Unexpected Deaths in Childhood Flow Chart has also been updated.


  1. Introduction
  2. If Concerns Develop that the Death may be Suspicious
  3. The Three Phases within the SUDIC Response Process (SRP)
  4. Practical Procedures for implementing the SUDIC Response Process (SRP)

    Appendix 1: Responding to Sudden Unexpected Deaths in Childhood Flow Chart

1. Introduction

These procedures set a minimum standard for responding to unexpected deaths in infancy and childhood as outlined in Chapter 5, Working Together to Safeguard Children. They should be followed when:

  • A decision is made that the death of the child is unexpected; or
  • There is a lack of clarity about whether the death of the child is unexpected.

Under the above statutory guidance, an unexpected death is defined as the death of an infant or child (less than 18 years old) which (excluding stillbirths):

  • 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.

It is the responsibility of the attending doctor and the Police to ascertain if the death is unexpected. If the opinion of the Sudden Unexpected Death in Childhood (SUDIC) Doctor is required, they can be contacted, via the Child Death Overview Panel office (CDOP), Monday - Friday, 9am-5pm, excluding bank holidays, on 0116 295 8715. Where professionals are uncertain, the processes for unexpected child deaths should be followed until the available evidence enables a different decision to be made.

Examples of unexpected deaths include:

  • Traffic accidents, suicides and murders, and any sudden unexpected/unexplained death in infancy childhood;
  • The unexpected death of a child who has a life-limiting condition but whose death was not anticipated as a significant possibility within the previous 24 hours;
  • Any child admitted to a hospital ward and who subsequently dies unexpectedly in hospital.

Children dying at home or in a hospice or other setting who have been undergoing end of life care will not usually be considered to have died unexpectedly, and a rapid response to such deaths is rarely indicated.

If an attending doctor is able to sign the death certificate, please see Section 2, Context, Child Death Overview Panel Procedure.

2. If Concerns Develop that the Death may be Suspicious

Significant concerns may be raised at any stage during these procedures by family members, or from any of the involved agencies, that neglect or abuse may be a contributory cause of the child's death. If this happens Leicester and Leicestershire and Rutland Safeguarding Children Boards' Child Protection Procedures will be followed. A verbal referral to the Police /Children's Social Care will be made immediately, and confirmed in writing, detailing the circumstances and nature of these concerns (see Leicester City LSCB and Leicestershire and Rutland LSCB Referrals to Children’s Social Care Procedure).

  1. If the Police decide that the death is now a matter for criminal investigation the balance of responsibility moves away from the healthcare professionals and the Police will take the lead role. Professionals may be required to provide statements;
  2. In cases where the death is now under criminal investigation the SUDIC Response Process (SRP) will be halted. The Child Death Review (CDR) Manager will maintain regular contact with the Police regarding developments. If there is insufficient evidence to pursue a criminal investigation the SRP procedure may be re-instigated at an appropriate phase, following discussion with the CDR Manager, SUDIC Doctor and Police;
  3. If there are other children in the household, or children who have significant contact with the family and suspicion develops at any stage that the death may be caused by neglect or abuse, child protection enquiries must be instigated (see Referrals to Children’s Social Care Procedure). Children's Social Care Services must be fully involved and take the lead in considering whether other children within the household need immediate protection;
  4. In all cases where emerging concerns around child protection are identified, the SUDIC Doctor must consult with relevant agencies and the CDR Manager and decide whether there is a need for an immediate Strategy Meeting (Section 47) or whether this can wait until the initial findings of the post mortem. This MAY take the place of an initial case discussion within the SRP led by the SUDIC Doctor;
  5. If information emerges which requires the Local Safeguarding Children Board (LSCB) Chair to request a Serious Case Review (SCR) in relation to the death of a child (in line with Serious Case Reviews, see Learning and Improvement Framework Procedure) the SRP will be halted. The CDR Manager will maintain close links with the respective agencies and ensure the CDOP Chair is kept informed. Upon completion of the SCR a summary will be forwarded to the CDR Manager to be included in discussion at Panel.

These procedures recognise the duty of care agencies have, to process communication, undertake collaborative action and information sharing following the unexpected death of a child, thereby achieving a safe, consistent and sensitive response to families. In particular, they are intended to:

  1. Enable the capturing of immediate information about unexpected child deaths with an open minded and balanced approach;
  2. Ensure opportunities for information gathering are not lost;
  3. Collate information in a standard format;
  4. Bring together relevant agencies to assess the information in an evidence based and measured manner, and evaluate the reasons for and circumstances for the death, in agreement with Her Majesty (HM) Coroner;
  5. Engage agencies appropriately post death, maintaining contact at regular intervals with family members and other professionals who have ongoing responsibilities to the family, to ensure that they are appropriately informed and supported.

3. The Three Phases within the SUDIC Response Process (SRP)

There are three distinct phases within these procedures describing the processes of communication, collaborative action and information sharing. These should be applied following the unexpected death of a child. In each of the 3 phases HM Coroner will be consulted and kept informed by the CDR Manager and Police as appropriate. HM Coroner assumes responsibility for the child's body and will decide which pathologist will complete the post mortem examination where relevant.

Phase 1: Initial enquiries: Initial enquiries: The collaborative process between the attending physician, and the Detective Inspector (DI) who is either on duty and covers the family address/incident location or is on call, in which a decision is made as to whether a child's death is expected or unexpected, and whether there are any suspicious circumstances. During office hours the CDR Manager is responsible for co-ordinating the multi-agency response and should immediately oversee that the following agencies/individuals have been notified:

Phase 2: Case discussion meeting: (5-7 days) A multi-agency meeting/telephone discussion which ensures that all agencies are informed and updated, that any concerns are identified and appropriately managed and detailed in resultant action plans.

Phase 3: Review: (20-26 weeks) This review identifies or confirms the cause of death and / or contributory factors at the point when the final post mortem report is available. This review also considers the future care for the family and where necessary support for professionals.

Issues to be considered throughout all three Phases are:

  1. The needs of the bereaved family should be taken into account at every stage. This includes the welfare and protection of remaining siblings, spiritual needs and possible involvement of the extended family;
  2. Any religious or cultural beliefs which may have an impact on these procedures should be taken into account. Issues must be dealt with sensitively, whilst maintaining a consistent approach to the procedure;
  3. It is important to recognise the emotional impact on staff involved with families where a child has died unexpectedly. All staff should have access to appropriate support within their own agencies;
  4. In certain circumstances a child's death may generate media interest and practitioners may be contacted by the media. In all cases practitioners should follow their own employers' agency communication strategy and refer the enquirer to the appropriate agency Department and where appropriate ensure HM Coroner is consulted. In all cases the CDOP Chair will be advised of relevant actions undertaken by the agency involved via their Single Point of Contact (SPOC);
  5. In high profile cases media attention and enquiries will be managed by the LSCB in collaboration with the Police and relevant Trusts / Agency Press officers, whilst ensuring HM Coroner is consulted.

4. Practical Procedures for implementing the SUDIC Response Process (SRP)

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

Phase 1: Initial enquiries

Role of the first professionals on the Scene

If the first professionals on the scene are not medical professionals, they must obtain urgent medical assistance as the first priority. Following the receipt of a call to the East Midlands Ambulance Service (EMAS) Control Centre the nearest available Emergency Response will be sent to the scene as detailed in Clinical Guidance Bulletin 51.


The Police will be informed and will attend in the majority of unexpected deaths from the outset. They are typically called with the other emergency services to most deaths and serious injuries.

Police officers attending the scene of any death will be following the Leicestershire Constabulary Procedure for the Investigation of Sudden, Unexpected and Questionable Deaths. In cases involving the unexpected death of a child the attending officer/s will make contact with the Detective Inspector who is either on duty and covers the family address / incident location or is on call for support and advice.

If the death is not thought to be suspicious then the officers will act on behalf of HM Coroner to record and report all material evidence and information.

East Midlands Ambulance Service (EMAS)

  1. On arrival, the child will be assessed with a Primary Survey and if required Advance or Intermediate Life Support (UK Resuscitation guidelines, 2010) will be commenced with immediate transport to the nearest Accident and Emergency (A & E) Department with a hospital alert call of expected time of arrival. This procedure does not interfere with the absolute priority of effective resuscitation, if this is possible;
  2. The EMAS crew attending will observe the scene and position of the child on arrival, identify persons present and record any accounts provided and include these details on their Patient Report Form (PRF), and if there is insufficient space to attach notes as this may be crucial to the process of making sense subsequently of the circumstances of the death;
  3. Following the primary survey and all checks for signs of life combined with the history of events the infant / child is obviously dead, the crew at the scene will liaise with the Police;
  4. Arrange for the child to be taken immediately to the A&E rather than to a mortuary whether or not the child is evidently dead;
  5. If there are clear signs which give rise to suspicions around the circumstances of the death the Police may request the body to remain at the scene for forensic examination. The crew will await the arrival of the DI who will make the decision if the scene is a crime scene. In this case the child will be left at the scene and the DI will sign the PRF accordingly;
  6. Prior to arrival at A & E the crew will forward relevant information and history to the waiting medical staff;
  7. A copy of the PRF, Diagnosis of Death and Registration of End of Life Care Decision documentation, where relevant, will be faxed to the CDR Manager.

General Practitioners

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

It is essential for the GP to contact the Police or HM Coroner's Officers if they are first on the scene, after taking into account their primary responsibility of saving life or declaring death. In these circumstances a GP may not issue the death certification, if the death is felt unexpected.

The GP will complete a CDOP Form A Notification of Child Death and where appropriate CDOP Form B Agency Report Form and forward to the CDR Manager.

Emergency Department and Other Hospital Settings

The first priority as in any such case will be the provision of medical assistance to the child.

As soon as practicable, the child should be examined by the attending doctor, Consultant Paediatrician or deputy.

The parents will be allocated a specific member of staff to provide support, advice and care with relevant details recorded in the child's records. Any relevant information by parents/carer about the circumstances of the death must also be recorded in writing in the child's records.

Once the child has been pronounced dead, HM Coroner assumes responsibility for the body and must be informed.

The attending doctor will:

  1. Ensure parents are kept fully informed of all proceedings, explaining future Police or Coroner involvement, including the Coroner's authority to order a post-mortem examination;
  2. Take a detailed and careful history of events leading up to and following discovery of the child's collapse from the parents/carers. It is important that, as far as possible, the parents or carers account of the events should be documented verbatim. Where there is any concern about the circumstances surrounding the child's death, consideration should be given to speaking with the parents / carers separately so that their accounts can be compared and verified;
  3. Obtain details of all other children and adults in the immediate family. This activity will also include consulting with the Children's Social Care Team to see if the child or other children in the household are subject to a Child Protection Plan;
  4. Will speak to the ambulance crew who attended the scene for the purposes of information gathering;
  5. Will speak to the member of staff initially allocated to provide support to the parents for the purposes of information gathering;
  6. Take investigative samples as per University Hospitals of Leicester (UHL) protocol.

Once points a) to f) have been completed, the Consultant in charge of the child or his deputy will consult with the Police, in order to jointly review the presenting information and to consider the appropriate course of action.

Initial Multi-Agency Enquiries

In all unexpected deaths the child's Consultant or attending doctor remains responsible to initiate multi-agency co-ordination. The Police and HM Coroner will be informed immediately together with the Children's Social Care Team, where relevant.

The attending doctor will decide in conjunction with the Detective Inspector (DI) whether the death is unexpected, but it would still trigger the SRP.

A joint visit by the Police and named nurse should always be considered for infants and children who die unexpectedly in a non-hospital setting.

If the Police wish to undertake an urgent scene visit, this can be undertaken without an accompanying named nurse.

If the death appeared to occur unexpectedly, but the child is known to have a life-limiting condition, the first step should be communication between the attending doctor, palliative care team and the DI to consider whether this death, although unexpected, is not unexplained.

The CDR Manager is responsible for co-ordinating the multi-agency response and should immediately oversee that the following agencies/individuals have been notified:

  • The Coroner;
  • The Police;
  • The Local Authority's Children's Social Care;
  • The GP;
  • The Health visitor/school nurse;
  • Any other known involved professional.

Joint Visit

If a joint visit is required the DI will ring the CDR Manager and arrange for a planned visit to be undertaken with the Named Nurse. Cover is provided by the named nurses Monday to Friday 9 am - 5pm (excluding bank holidays)

The DI will normally identify a Detective Constable (DC) to be the Officer in the Case (OIC) both for the HM Coroner investigation and for this process, who with the Named Nurse will obtain information relevant to the child's death. The Named Nurse will be responsible for explaining to the parents the CDOP procedure, building on and supporting any information already offered to the parents, including providing a copy of the CDOP Leaflet for Parents, if this has not already been given to them in A&E.

  1. The Named Nurse will provide appropriate information and initial support to relatives, carers and friends affected by the death and undertake an assessment of needs including recommendations in relation to ongoing support and feedback to the case discussion meeting (Phase 2); they will ensure that families are aware of the CDOP process and its remit. Consent is not required to access the child’s records. If siblings/family member’s records are to be accessed consent will be sought;
  2. The CDR Manager will take responsibility to ensure the needs of the family are considered throughout the process and ensure support is offered to the family as required. If an appointment with the CDOP Chair is requested, the CDR Manager will facilitate this, to try to resolve any concerns or anxieties they may have (see Family and Professional Support of Child Death Overview Panel Procedure);
  3. Following the joint visit the SUDIC Doctor may decide to undertake a home visit with other key professionals as appropriate, to clarify information or ask additional questions. This will provide parents with an early opportunity to ask questions and to be provided with relevant information as agreed.

Notification & Documentation Process following the unexpected death of a child

Any agency or professional who becomes aware of a child's death during 9am- 5pm Monday to Friday, should notify the CDR Manager immediately.

Where the death relates to a child aged 28 days or under and it is not clear whether the death was expected or unexpected, discussion will take place with the Neo-Natal Unit (NNU) medical staff, and DI (during office hours advice can also be sought from the SUDIC Doctor's by contacting the CDR manager on 0116 295 8715).

HM Coroner officer has a key role in ensuring that the CDR Manager is informed of relevant unexpected child deaths under Rule 57A within 72 hours. In addition the CDOP office will inform HM Coroner of relevant deaths notified to the CDR Manager.

The CDR Manager will then request additional information from relevant agencies. Where possible a known named professional will be contacted. A request for information will be sent within 1-2 working days of notification of child's death.

CDOP Form Bs should be returned completed with as much information as possible within 10 working days. At the discretion of the CDR Manager CDOP Form Bs may be returned to agencies with a request for additional information.

If agencies do not return the documentation within the requested timescales, the CDR Manager will take further action. Persistent failure to provide information will be highlighted to the CDOP Chair and raised with the Local Safeguarding Children Board.

Phase 2: within 5-7 days

The CDR Manager in conjunction with the SUDIC Doctor will arrange a case discussion meeting/telephone discussion to take place within 5-7days. If available the preliminary post mortem results will be discussed at this stage. The case discussion may involve:

  • The DI or Officer in the Case (OIC);
  • Named Nurse undertaking the joint visit;
  • All relevant health professionals, i.e. GP, HV, Midwife;
  • Children's Social Care, where relevant;
  • Professionals from relevant other agencies i.e. school.

In all cases of unexpected death the SUDIC Doctor may also, at this stage, make appropriate arrangements for the family to be seen again. The SUDIC Doctor may visit either the family home or identify another health professional to undertake this visit on their behalf. The Senior Detective may also wish to attend this subsequent meeting to inform the family about Police and Coronial procedures.

Following the meeting, the CDR Manager will collate actions identified and will ensure dissemination as appropriate. The CDR Manager may also request additional information from agencies to assist in further case discussions. In all cases, any inter-agency discussions should include establishing a clear plan for support to the bereaved family. A member of staff will be identified to offer ongoing support to the family as detailed in any action plan. It will be the responsibility of the CDR Manager to monitor that the action plan recommendations are met.

Phase 3: within 20-26 weeks

In all unexpected cases the CDR Manager will co-ordinate a further multi-agency meeting chaired by the SUDIC Doctor involving relevant professionals following the final results of the post-mortem examination becoming known and collation of agency information about the child and family.

Those requested to attend may involve those who knew the family and child, and those involved in investigating the death, for example:

  • The DI or (OIC);
  • Named Nurse who undertook the joint visit;
  • All relevant health professionals, i.e. GP, HV, Midwife;
  • Children's Social Care, where relevant;
  • Professionals from relevant other agencies i.e. school.

The purpose of the meeting is to:

  1. Share information concerning the circumstances of the death, the child's history, family history and subsequent investigations and identify the cause of death and/or those factors that may have contributed to the death;
  2. Plan future care for the family, including how the parents/carers will be informed of the outcome of the meeting and how they will be provided with ongoing support;
  3. Complete DCSF Analysis Proforma C and forward a copy to the CDOP Panel and HM Coroner (where requested);
  4. Ensure any relevant information is forwarded to HM Coroner in a timely manner;
  5. Where appropriate identify support for professionals involved.

Potential lessons to be learnt may be identified at this stage. The outcome of the meeting may also inform the inquest, if there is one. The possibility of abuse or neglect as cause or contributory factor in the death should be explicitly addressed where relevant and the outcome recorded.

In certain circumstances Phase 3 may be delayed or undertaken within another process. These circumstances include for example:

  • Criminal Investigations;
  • HM Coroner's Inquest;
  • Serious Case Reviews;
  • Child Protection Procedures;
  • Legal Proceedings;
  • Health & Safety Executive;
  • MAPPA.

In these instances a summary report will be submitted by the Agency to the CDR Manager.

Following the meeting, the CDR Manager will collate actions identified and will ensure dissemination as appropriate.

Ongoing Care of the Bereaved Family

The death of a child will be a traumatic loss for a family. Bereaved family members, parents and children, may require support to assist them in the bereavement process. All agencies dealing with the family should have the relevant skills and training in order to aid this process.

Ensuring at every phase that the needs of the bereaved family are considered can be assisted by:

  1. Providing information in written form and ensuring appropriate ongoing information is shared by the identified professional as agreed at each phase of the process;
  2. Agreeing at each phase, which agency and lead professional will be responsible for supporting the family, including what information can or cannot be shared following consultation with the Police / HM Coroner. There will be an agreed format to ensure congruent information sharing;
  3. Providing opportunities to ask questions at different stages in the process are made available. Support to the family should be part of the SUDIC response process, and any actions or assessment of needs including recommendations are shared in writing to ensure they are incorporated within any inter-agency planning coordinated by the CDR Manager, SUDIC Doctor and Named Nurses.

Post Mortems

All cases of unexpected death should be reported to HM Coroner and the decision may be taken to request a post mortem. In respect of sudden unexpected death in infancy it should be carried out by a paediatric pathologist within 48 hours of the child's death, or as soon as reasonably practical thereafter. If there is anything to suggest that the circumstances of the death are suspicious or of an unnatural cause, the post mortem examination should also involve a Home Office Forensic Pathologist.

Prior to the post mortem examination, the pathologist should be fully briefed on the details of the child's recent and past medical history and physical findings at presentation and interventions undertaken by the consultant paediatrician involved, via the HM Coroner's Officer. This should include the findings of the joint visit by the Named Nurse and Detective Inspector. This includes viewing any photographs and videos of the death scene or child.

The pathologists should discuss the preliminary results of the post mortem examination with the Coroner. HM Coroner will then liaise with the CDR Manager and SUDIC doctors. This information will be shared at the case discussion meeting Phase 2.

Appendix 1: Responding to Sudden Unexpected Deaths in Childhood Flowchart

Click here to view flowchart