3.1 Rapid Response to an Unexpected Child Death

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A Guide to Investigating Child Deaths (College of Policing, 2014)

At all stages of these procedures, practitioners should consider:

  1. Whether a referral for child protection under Section 47 is required;
  2. Whether the criteria for a Serious Case Review (or other review) might apply in which case, the MKSCB office should be contacted, the Serious Case Review Procedure should be followed, and a MKSCB SCR referral form should be completed and submitted to the MKSCB office;
  3. Sensitivity to the needs of parents and siblings including bereavement support;
  4. Does the child death meet the criteria for reporting by the local authority to Ofsted as a notifiable incident (see Working Together to Safeguard Children 2015).


This chapter was revised in October 2015 to take account of Working Together to Safeguard Children 2015, changes in Coronial procedures and revised interagency working processes following the implementation of Milton Keynes Multi-Agency Safeguarding Hub (MASH)


1. Introduction

1.1 This procedure was first produced in response to 'Working Together to Safeguard Children, 2006'. It has since been updated in response to local and national developments, including the revised Working Together 2015. It forms the basis of the inter-agency response to an unexpected death of a child in Milton Keynes.

2. Notes on Definitions

2.1 "Childhood" is defined as the time from live birth (irrespective of gestation) until the attainment of the age of 18 years. By far the largest group of child deaths occurs in the perinatal period (0 - 7 days). For "rapid response" procedures these infants will not be routinely included unless involved professionals express concerns about the circumstances of the pregnancy or the death. 
2.2 "Responsible consultant" has been used to identify the senior involved clinician, this is most likely to be a paediatrician but when the death is that of a young person of over 16 years the clinician will be an adult specialist and some interpretation of the protocol depending on age and mode of death may be required. 
2.3 "Unexpected death" is defined in Working Together to Safeguard Children 2015 (Chapter 5, paragraph 12) as 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 an unexpected collapse or incident leading to or precipitating the events which led to the death.

"Death" means the time that death is formally certified. It is clearly not appropriate to instigate this process whilst the child is alive and receiving medical care. However, in cases where the medical team have any concerns that there are issues of abuse or neglect when a child has presented in a critical condition, especially where there are other children in the household, then early discussion with Police and Children's Social Care (CSC) should take place. This will allow scrutiny of the CSC and Police databases as a minimum precaution and further inter-agency involvement as considered necessary. These preliminary enquiries can be made without informing the parents if it is considered that this will add to their distress.

Rapid Response procedures may need to be considered in a young person over 18 years old in the exceptional circumstance where the unexpected collapse or incident leading to or precipitating the events which led to death occurred when the young person was under 18 years old.

3. Agency Roles and Responsibilities

3.1 Once a child has been declared dead, the Coroner has jurisdiction over the body and all that pertains to it.
3.2 The majority of unexpected deaths in childhood are natural tragedies, but a minority are a consequence of ignorance, neglect, abuse or homicide. The investigation should keep an appropriate balance between medical and forensic requirements and the needs of the family in coping with the tragedy. Account should be taken of possible risks to other children in the household.
3.3 Professionals should approach the investigation with an open mind and families should be treated with sensitivity, discretion and respect. Professionals must be aware that as the number of child deaths due to natural causes decreases, the proportion of such deaths which could be attributed to neglect or abuse is likely to increase.
3.4 There should be a multi-agency approach involving collaboration among: emergency department (ED) staff, ambulance staff, named and designated doctors and nurses in child protection, Coroners, coroners' officers, general practitioners (GP's), health visitors, midwives, paediatricians, pathologists, police, social workers and education.
3.5 In each agency a senior person with suitable training and experience should be identified as having responsibility for implementation of the protocol, including continuing training for all relevant staff.
3.6 The Designated Paediatrician for Unexpected Deaths in Childhood will take the strategic lead for rapid response within Health, but the input at senior level in individual cases will be from the consultant involved in the initial event as at present (responsible consultant).
3.7 The Duty Detective Inspector for the Local Police area will lead for the Police on initial rapid response to Child Death. Subsequent enquiries will be led by the Local Police area Detective Inspector for the Child Abuse Investigation Unit (CAIU) and the Team Manager (Multi Agency Safeguarding Hub) for the local authority.
3.8 Children found dead at home should usually be taken into the emergency department, not to the mortuary, and resuscitation should be initiated unless clearly inappropriate. Ambulance crew must contact the police with full incident details as soon as it is apparent that a child is in cardiac/ respiratory arrest. There are situations where it is obvious that a body is beyond resuscitation and needs either to remain at the death scene for forensic purposes or to be moved to a mortuary. This will be a decision for the police in consultation with the Coroner as outlined in the Murder Investigation Manual or in the case of road deaths, the Road Death Investigation Manual.
3.9 On arrival in the emergency department the parents/carers should be allocated a member of staff to care for them and should normally be given the opportunity to hold and spend time with their child at a later point while in the department. They should also be offered mementoes e.g. a lock of hair or a photo. 
3.10 As soon as possible after arrival, the child should be examined by the responsible consultant and a careful history should be taken from the parents. 
3.11 A standard set of investigative samples should be taken. This list is available in the emergency department and on the MKHFT safeguarding children intranet pages.  
3.12 When the child is pronounced dead, the responsible consultant should inform the parents/carers, and explain the Coroner, Police and Children’s Social Care involvement and the need for a post-mortem examination. The opportunity to donate tissues or organs would only occur in the situation where life support on an Intensive Care Unit following collapse was being withdrawn and there was an opportunity to seek the Coroner's permission.
3.13 As soon as death has been confirmed, notification should be given to the Coroner (via the Coroner's Officer), the Police, Children’s Social Care and the primary care team.
3.14 Further notification of the child's death, should be completed, as per the "Procedure for sudden unexpected death of a child’ within the Safeguarding Children policy for Milton Keynes University Hospital NHS Foundation Trust", this includes completion of the checklist which is then forwarded to the MKSCB CDOP Co-ordinator.
3.15 When a child goes directly to the mortuary the on-call clinical team (paediatric or adult) should be informed so that urgent specimens can be obtained as necessary and support for the bereaved can be organised.


4. Initial Case Review Discussion


The duty Social Worker is contacted by the responsible consultant or Duty Detective and a Multi Agency Referral Form (MARF) is completed by them and forwarded to the Milton Keynes Multi Agency Safeguarding Hub (MASH). An initial Case Review Discussion should be held between the lead professionals (the involved clinician, the senior investigating officer in consultation with the CAIU DI and the MASH at Children's Social Care). This is usually done by telephone by the involved clinician but should be initiated by the agency that has the initial contact with the child if not Health.

The circumstances of the child’s death and initial discussions involving the clinicians in consultation with the Police Senior Investigating Officer (SIO) needs to be incorporated into the MARF.

In the event of a child dying out of hours, the out of hour’s duty team will be involved in the case review discussion and refer into MASH for the next working day.

The purpose of the Case Review Discussion is for agencies:

  • To agree their approach;
  • To ensure continuing close collaboration;
  • To ascertain whether any agency has any relevant information about the child, other close family members and members of the household.

In most cases a multi agency discussion will take place within the Milton Keynes MASH. Depending on the outcome of this discussion a Strategy Meeting under Section 47 Children Act may be convened by Children’s Social Care. There will be situations where the circumstances of the death are straightforward and this is not required.

The outcome from the MASH case review discussion or any Section 47 Strategy Meeting should be sent to the Coroner’s Office by a practitioner in the MASH. Depending on the discussions at the meeting, reports for the Coroner may be requested from:

  • Education (Head Teacher of the child’s school);
  • Social Care;
  • NHS Safeguarding Children Team;
  • Any other relevant party.
4.3 If the death is suspicious or significant concerns are raised at any stage about the possibility of abuse or neglect, a decision will be taken for the police to become the lead agency, and take primacy in the investigation. In these circumstances the Duty DI will inform a Senior Investigating Officer (SIO) from Major Crime. A decision will then be made about who will take responsibility for investigating the child's death. In these circumstances consultation must take place with the police, to ensure no compromise of information to the parents/carers or those close to them, who may be responsible for or contributed to the cause of death.  In all other cases, Health remains the lead agency.
4.4 If it is thought at any time that the criteria for a Serious Case Review might apply, the Chair of the MKSCB should be contacted and the Serious Case Review Proceduresshould be followed.    
4.5 When a baby or older child dies unexpectedly, the police are responsible for investigating the circumstances of the death, and may have to secure the death scene. There will be a visit to the scene of the death (preferably within 24 hours). This home visit is by the Police as part of the forensic investigative process; additional clinical expertise will be accessed as part of this process where necessary. Following an initial review of the scene by the Police, if expert clinical opinion is required the material gathered by the police will be reviewed and assessed jointly. The Police are responsible for providing the Coroner with a report from the scene visit and subsequent investigation into the death. In addition to notifying the Coroner, the police will notify the MASH of the outcome of the home visit to enable re-evaluation of the information and reconsideration of whether a s47 strategy meeting is required. The CDOP co-ordinator should also be notified in order to track and coordination of the Rapid Response process.
4.6 A copy of the medical notes will be made available to the Coroner and the pathologist. The details of the involved clinician MUST be clearly recorded on the medical records. It must be clear on the medical records who the lead clinician is, to facilitate discussion between the pathologist and the lead clinician. This is particularly important in cases where a forensic pathologist is required.
4.7 The Coroner’s Office will complete a Form A which will indicate whether or not a post-mortem examination will be carried out. Completed A forms should be sent to the MKSCB CDOP Co-ordinator The coroner will order a post-mortem examination to be carried out as soon as possible, preferably within 48 hours, by the most appropriate pathologist. In most cases, this will be a paediatric pathologist, following a recommended protocol, but if significant concerns have been raised about the possibility of homicide, abuse or neglect, a Home Office approved paediatric pathologist should take the lead. If the post-mortem examination reveals no sufficient identifiable cause of death, whether or not any concerns have been raised during the post-mortem examination or previously about the possibility of abuse or neglect, the pathologist should categorise the death as "unexplained pending further investigations". The coroner should hold an investigation into every case which may lead to an inquest, if death is not due to natural causes. This process would apply when the final post-mortem report is available.
4.8 Following the initial Post-mortem results, an MDT meeting/discussion occurs with all professionals involved. The Coroner/Police/Paediatrician will discuss the results of the initial post-mortem (either directly or by email). This discussion, the decisions made and any actions taken should be to be copied to the CDOP Co-ordinator. Confirmation of the discussion, and the post-mortem report should also be sent to the MKSCB CDOP Co-ordinator.

If the post mortem indicates death from abuse or neglect:   

  • The Police will commence a criminal investigation;
  • Action will be taken to safeguard other children in the household by being referred through the MK MASH in order for appropriate action to be taken;
  • The MKSCB Chair, and the MKSCB Office should be notified, via or 01908 254373, and an MKSCB SCR referral form should be completed in order for a referral to be made to the MKSCB Serious Case Review Sub-Group.

The autopsy report will be forwarded to the responsible consultant and to the Lead Paediatrician for Child Death. Either (or both together) should discuss the results of the autopsy with the parents/carers at the earliest opportunity:

  • If the Coroner does not want such a discussion prior to the Inquest the rider “not to be discussed” will be added to the autopsy report;
  • If the Police have taken over as lead agency because of concerns over abuse or neglect then the role for and conduct of such a meeting will be discussed;
  • If the autopsy findings are unclear or controversial the responsible consultant/ Designated Paediatrician and the Coroner/Police will discuss on a case by case basis;
  • There may be further reasons not to hold a meeting, for example where the Inquest is to take place soon after the release of the autopsy report or when there are issues around litigation.
4.11 The parents/carers will receive written information advising that the child's death will be subject to a review by the Child Death Overview Panel (CDOP) in order to learn any lessons that may help to prevent future deaths of children (see Child Death Overview Panel Procedure).


5. Coroner’s Investigation and Inquest

5.1 HM Coroner in Milton Keynes holds an investigation into all sudden unexpected deaths in childhood and an inquest will be held if a cause of death is not ascertained. The information shared as in the above paragraphs will contribute to this process.

The purpose of an Inquest is to determine

  • Who has died;
  • When and where the death occurred;
  • How the cause of death arose.


6. After the Inquest

6.1 If the verdict of the inquest is that abuse and neglect caused or contributed to the death the Police and Children’s Social Care will act accordingly and the need for a Serious Case Review will be considered (if these have not previously occurred).
6.2 If the child’s family have any unanswered questions concerning the death the responsible consultant or Designated Paediatrician for unexpected deaths in Childhood (or both) will meet them to answer their questions. If the family do not wish contact this may be done by letter.
6.3 The Designated Paediatrician for unexpected deaths in childhood will consider whether a professionals meeting is required to consider the needs of other children in the family or future children and will convene and chair this meeting. It is expected that SUDI cases are discussed in this way.
6.4 In the case of SUDI it should be noted that if there are subsequent pregnancies in the mother will be offered a referral to the Care of the Next Infant (CONI) programme at booking.
6.5 All information and the standard data set will be forwarded to the Child Death Overview Panel
6.6 Where it is anticipated that this may become a high-profile case the MKSCB will co-ordinate a media response/communication strategy between MKSCB partners.


7. When a Child Dies Out of Area

Where a child (usually resident in Milton Keynes) dies out of area, communication should go through the MKSCB single point of contact: 01908 254373 who and we will invoke these procedures.


8. Abbreviations and Acronyms

CAI Child Abuse Investigation Unit
CONI Care of Next Infant
CSC Children's Social Care
DI Detective Inspector
GP General Practitioner
LPA Local Policing Area
SID Sudden Infant Death
SIO Senior Investigating Officer (Police)
SUDI Sudden Unexpected Death of an Infant


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