3.1 Milton Keynes Child Death Review Procedures
At all stages of these procedures, practitioners should consider:
- Whether a referral for child protection under Section 47 is required;
- Sensitivity to the needs of parents and siblings including bereavement support;
- Does the child death meet the criteria for reporting by the local authority to Ofsted as a serious incident (see Working Together to Safeguard Children 2018).
- Be mindful of the need to follow the statutory Child Death Review Operational Guidance 2018.
This chapter was revised in 2020 to take account of Working Together to Safeguard Children 2018, and Child Death Review Operational Guidance 2018.
- 1. Introduction
- 2. Immediate Decision-Making and Notification
- 3. Initial Case Review Discussion
- 4. Child Death Review
- 5. Child Death Review Meeting
- 6. Child Death Overview Panel/Child Death Board
- 7. Membership, Chairing and Expectations of CDOP
- 8. Abbreviations and Acronyms
- Coroner's Office and Inquest
This chapter has been revised in response to publication of Working Together 2018 and Child Death Review Operational Guidance 2018.
Working Together 2018, Chapter 5, identifies the statutory requirements of child death review partners to make arrangements to review the deaths of children normally resident in the local area. The child death review partners for Milton Keynes are Milton Keynes Council and Milton Keynes Clinical Commissioning Group.
The Milton Keynes procedures should be followed by all organisations that had contact with a child and/or their families, and therefore will have vital information to contribute to the review process. The process of expertly reviewing all child deaths is grounded in respect for the rights of children and their families, with the intention of helping to prevent future child deaths. Ensuring appropriate support and follow-up is available for the family is a key part of the child death review process.
Agencies should be aware of their responsibilities in the child death review process: information may be requested from a person or organisation for the purposes of enabling and assisting the review and/or analysis process. Working Together guidance is very clear in stating that ‘The person or organisation must comply with the request, and if they do not, child death review partners may take legal action to seek enforcement’.
The following sections explain the various stages in the process of reviewing a child death, and the responsibilities of the various agencies.
2. Immediate Decision-Making and Notification
|2.1||Within 1 – 2 hours of a child's death, senior professionals involved at that time should:
A written record of the responses to the above points should be made.
Within 24 hours (or the next working day) of the child’s death
Within 24 hours of the child’s death the attending healthcare team should notify the following:
Any professional who becomes aware of a child death should notify the MK Together Partnership Support Officer by completing a Child Death Notification form and emailing it to email@example.com . Information can also be phoned through via 01908 254373.
MKUHFT colleagues should also complete the checklist, available via MKUHFT intranet.
If there are concerns about the circumstances of the child’s death, or the child’s death was unexpected (not anticipated in the 24 hours before death) Police, Children’s Social Care, Health and the Coroner’s Office should have a discussion about the circumstances of the death to consider if a Joint Agency Response is required.
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.
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.
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.
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.
A standard set of investigative samples should be taken. This list is available in the emergency department and on the MKUHFT safeguarding children intranet pages.
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.
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.
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 should be forwarded to the CDOP Co-ordinator (firstname.lastname@example.org ).
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.
3. Initial Case Review Discussion
|3.1||The MASH should contacted by the responsible consultant or Duty Detective and 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|
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:
|3.4||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.|
|3.5||The outcome from the MASH case review discussion or any Section 47 Strategy Meeting should be sent to the Coroner’s Office and the CDOP Co-ordinator (email@example.com) by a practitioner in the MASH. Depending on the discussions at the meeting, reports for the Coroner may be requested from a range of agencies who had contact with the child and/or their family.|
|3.6||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|
|3.7||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 of the outcome|
|3.8||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.|
|3.9||The Coroner’s Office will indicate whether or not a post-mortem examination will be carried out and in cases where there will be a post mortem the CDOP Co-ordinator should be notified. 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.|
|3.10||Following the initial Post-mortem results, an MDT meeting/discussion should take place 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 copied to the CDOP Co-ordinator. Confirmation of the discussion, and the post-mortem report should also be sent to the CDOP Co-ordinator.|
If the post mortem indicates death from abuse or neglect:
The autopsy report should 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:
|3.13||The parents/carers should be given written information advising that the child's death will be subject to discussions by professionals as part of a statutory process in order to learn any lessons that may help to prevent future deaths of children.|
4. Child Death Review
On receipt of the child death notification information the MK Together Partnership Support Officer will:
Agencies will be asked to complete the Child Death Reporting Form with as much relevant information available on their systems and submit to the Officer as soon as possible. Agencies should include on the reporting form any information in relation to bereavement support offered to the family and any follow-up arrangements that have been offered.
All the information gathered at this stage will be made available to the child death review meeting, which is the next step in the child death review process.
5. Child Death Review Meeting
The focus of each child death review meeting is on the individual child and their death.
Aims of the Child Death Review Meeting:
Notes of the meeting should be taken to help with completion of the draft child death analysis form which should then be sent to the MK Together Partnership Support Officer.
It is the responsibility of the organisation responsible for the declaration of death to arrange the CDRM. In practice, a medical organisation, such as a NHS Trust, or Hospice would be the most appropriate place to hold the majority of child death review meetings. The exception to this is when a Joint Agency Response has occurred, in which case responsibility falls to the lead health professional.
The Child Death Review Meeting (CDRM) is a multi-professional meeting where all matters relating to an individual child’s death are discussed by the professionals directly involved in the care of that child during life and their investigation after death. The meeting should be chaired by the lead professional within the organisation where the death was declared, or the lead health professional following a Joint Agency Response.
The nature of the meeting will vary according to the circumstances of the death and the practitioners involved. The CDRM could take the form of a final case discussion following a Joint Agency Response (JAR), a perinatal mortality review group meeting in the case of a baby who dies in a neo-natal unit, a hospital-based mortality meeting following the death of a child in a paediatric intensive care unit, or similar case discussion. Where the death occurs of a child with a life-limiting condition, and where the child and family was being supported by a hospice it would be most appropriate for the child death review meeting to be led by the hospice, with the support of the MK Together Partnership Support Officer.
The child death review meeting should take place once all investigations (eg Serious Incident investigation or Post Mortem examination) have concluded, and reports from key agencies have been received.
Statutory Child Death Review guidance indicates it is best practice to hold a child death review meeting within three months of the child’s death, and should take place before any Coroner inquest. The child death review meeting should also proceed where there is a criminal investigation, or prosecution, but there must be consultation with the Senior Investigating Officer (SIO). The child death review meeting cannot take place if the criminal investigation is directed at professionals involved in the care of the child – when prior group discussion might prejudice testimony in court.
The child death review meeting is a meeting for professionals, however, parents should be informed of the meeting by a key worker and be given the opportunity to contribute their views and questions through their key worker.
At the conclusion of the CDRM there should be a clear record of what follow up meetings have already occurred with the parents and who will be responsible for reporting back to the parents following the meeting. This feedback will generally be given by the child’s paediatrician, or in the case of a neonatal death, obstetrician and neonatologist. In cases where there has been a coroner investigation, the coroner’s office is ideally placed to take responsibility for this feedback.
Out of Area Child Death Reviews
Where the death of a Milton Keynes child occurred in another area, the responsibility for arranging the child death review meeting involving those professionals who were involved in the care of the child at the time of their death, or the investigation of their death, is the responsibility of the setting where the child died.
6. Child Death Overview Panel/Child Death Board
In Milton Keynes the responsibility for the final analysis of child deaths lies with the Child Death Affiliated Board/CDOP.
To better enable thematic learning and identify potential local safeguarding or health issues that could be modified in order to protect children from harm the Milton Keynes CDOP (Child Death Board) works closely with its counterparts in the Bedford and Luton CDOPs, to share learning.
Responsibility of Child Death Board
to collect and collate information about each child death, seeking relevant information from professionals and, where appropriate, family members
to analyse the anonymised information obtained, including the report from the CDRM, in order to confirm or clarify the cause of death, to determine any contributory factors, and to identify learning arising from the child death review process that may prevent future child deaths
The Child Death Board will aim to review all children’s deaths within six weeks of receiving the report from the CDRM, or the result of the coroner’s inquest.
7. Membership, Chairing and Expectations of CDOP
Statutory guidance requires that the CDOP is chaired by someone independent of the key providers (NHS, Social Care, Police) in the area. In Milton Keynes the Child Death Affiliated Board is chaired by the Director of Public Health.
Statutory guidance also requires membership of the CDOP/Child Death Affiliate Board to include the following professionals and senior representatives of the various agencies:
- Designated Doctor for Child Deaths
- Designated Doctor or Safeguarding Nurse
- Social Care
- Primary Care (GP or health visitor)
- Nursing and Midwifery
- Additional representatives as identified for a specific case
- Coroner’s Office
The expectation is that members of the Child Death Affiliated Board will read all relevant material in advance of the meeting.
The MK Together Child Death Affiliated Board will consider anonymised information, including the draft Analysis Form submitted by the Child Death Review Meeting, and will record their views and analysis on the same form
8. Abbreviations and Acronyms
|CAI||Child Abuse Investigation Unit|
|CONI||Care of Next Infant|
|CSC||Children's Social Care|
|LPA||Local Policing Area|
|SID||Sudden Infant Death|
|SIO||Senior Investigating Officer (Police)|
|SUDI||Sudden Unexpected Death of an Infant|
Coroner's Office and Inquest
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
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.
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