4.1 Investigation of Sudden Unexpected Deaths in Childhood
RELEVANT GUIDANCESudden Unexpected Death in Infancy and Childhood - Multi-agency Guidelines for Care and Investigation (Royal College of Pathologists, endorsed by The Royal College of Paediatrics and Child Health (2016)
This procedure outlines the multi-agency process for investigating unexpected deaths, described in Chapter 5 of Working Together to Safeguard Children. It describes the rapid response by a group of key professionals who come together for the purpose of enquiring into and evaluating each unexpected death of a child.
The detailed clinical guidelines to be followed within the appropriate hospital are contained in its clinical procedures.
An unexpected death is defined as:
- The death of a child (from birth to 18th birthday) which was NOT anticipated as a significant possibility 24 hours before the death;
- A similarly unexpected collapse leading to or precipitating the events which led to the death.
The determination that the death of a child meets the definition of a sudden unexpected death will usually be made by the attending Paediatrician or Consultant in Emergency Medicine. If in doubt, this procedure should be followed, and discussed with the Designated Paediatrician for Sudden Unexpected Death in Childhood (SUDIC) on the next working day. In some cases, the procedure may need to be followed until available evidence enables a different decision to be made.
Children dying in hospital who fulfil the definition above (e.g. those who have been ventilated following an unexpected collapse or injury) will have some parts of the investigative pathway completed as part of their clinical care. In such cases, the body will not be taken to the Emergency Department, but this procedure for investigating deaths will be followed at the appropriate point in the pathway.
3. Immediate Response to an Unexpected Child Death
Where a death is considered suspicious and it is likely that a police investigation will take place, an early Strategy Discussion should take place between the Paediatrician/Consultant in Emergency Medicine and the Senior Investigating Police Officer. The aim of this is to develop a line of communication for the exchange of information to complement the Police investigation and to add value to both processes.
The child's body should be taken by Yorkshire Ambulance Service (YAS) to the Emergency Department, not the mortuary, and resuscitation should always be initiated unless it is clearly inappropriate. YAS protocols indicate that the Police will normally be contacted, and the body should only be taken to the Emergency Department with the consent of the attending Police Officer, as the Police may require the body to remain at the scene for forensic examination. In these cases, the Coroner will direct removal.
In summary, the responsibilities of the Paediatrician (or Consultant in Emergency Medicine) include:
- Informing the parents about the death and explaining next steps. This should include an explanation of the process outlined in this protocol, which may be supported by a local leaflet;
- Ensuring full liaison with the police in the event of a suspicious death;
- Where there is concern that the death is suspicious, a decision as to what information is shared and how it is disclosed to parents should be determined by the senior investigating police officer;
- Deciding whether the death is unexpected;
- Notifying the Coroner;
- Taking history, examination and samples;
- Checking whether the child is known to Children's Social Care, and acting on immediate concern for siblings;
- Gathering early information via telephone discussion with Police, Children's Social Care, Coroner's Office and possible others involved in the child's care (depending on time of day) such as GP, school, Early Years setting;
- Collating all relevant information and sharing it with the pathologist prior to the post-mortem;
- Notifying the Designated Doctor for SUDIC as soon as possible (this may be the next working day depending when the child is brought in);
- Notifying the Named and/or Designated Doctor for Child Protection; and
- Arrange for follow-up with parents.
The Emergency Department Nurse will provide immediate support to the parents.
The most senior paediatrician available will undertake a detailed history, examination and collection of specimens as agreed with the Coroner (see the appropriate hospital's clinical guidelines). The collection of mementos (e.g. handprints, locks of hair), and the removal of tubes and IVs may only be done with the consent of the Coroner's Office.
The Paediatrician should immediately inform:
- The Coroner;
- The Police (if not already aware);
- Children's Social Care.
An immediate check should be done with Children's Social Care for the relevant area (see Local Contacts) to check whether the child is known to Children's Social Care, but this does not represent a referral. Children's Social Care can respond urgently if there are issues such as concern about the safety of siblings. This would represent a referral (see the Referrals Procedure) but should only be done if there are immediate concerns. Otherwise a formal notification should be made to the Safeguarding and Reviewing Unit in Children's Social Care for the relevant area (see Local Contacts).
4. Early Information Gathering (Same Day)
The Paediatrician (or Consultant in Emergency Medicine) should lead the process of early information gathering, which will comprise an early discussion involving all lead agencies.
This will normally take place on the telephone and should include:
- Children's Social Care;
- Coroner's Office;
- Other involved in the child's care e.g. GP, School, Early Years, CAMHS (this will depend upon the time of day when the child is brought in).
The purpose of the discussion is to gain commitment to gathering as much information as possible about the circumstances of the death and also to plan the next steps, including arrangements for close collaboration and communication as appropriate.
The involvement of the Police (on behalf of the Coroner) will take place in accordance with the National Police College guidelines, including the ordering of a post-mortem examination. The post-mortem will be undertaken in accordance with the guidelines and protocols laid down by the Royal College of Pathologists.
The Paediatrician, Consultant in Emergency Medicine and senior nurse involved with the child should follow Trust procedures for reporting and handling serious untoward incidents.
5. Notification to SUDIC Paediatrician/Team and Others (Same Day or Next Working Day for out-of-hours Cases)
Where a death is considered suspicious and it is likely that a police investigation will take place, an early strategy discussion should take place between the Paediatrician/Consultant in Emergency Medicine and the Senior Investigating Police Officer. The aim of this is to develop a line of communication for the exchange of information to complement the Police investigation and to add value to both processes.
Handover to the SUDIC Paediatrician/Team by the Paediatrician (or Consultant in Emergency Medicine) should take place after early telephone discussion is complete or on the next working day for children brought in out-of-hours. The SUDIC Paediatrician/Team will be available within normal working hours only. Handover should include details of the child, and all information gathered during the immediate and early information gathering phases, including copies of clinical notes, completed proformas or reports.
The Paediatrician (or Consultant in Emergency Medicine) should notify:
- The SUDIC Paediatrician/Team;
- The Designated and/or Named Doctor for Child Protection;
- The General Practitioner;
- The Child Death Overview Panel Coordinator; and
- Others as indicated in local protocols.
The SUDIC Paediatrician /Team should ensure that all relevant information is collated and shared with the pathologist prior to the post-mortem.
For children normally resident in another local authority area, this is the point at which the Child Death Review arrangements in the home area should take over. The Paediatrician (or Consultant in Emergency Medicine) must still notify the local SUDIC Paediatrician/Team about the death. The task of handing over responsibility to the SUDIC Paediatrician/Team in the area of the child's usual residence lies with the local SUDIC Paediatrician/Team in the area where the death takes place
6. Visit to the Place of Death
Decisions regarding the appropriateness of a visit to the place where the child died will be taken by the SUDIC Paediatrician/Team, in discussion with the Senior Investigating Police Officer.
The following principles will be taken into account when deciding whether a home visit will take place:
- Visits will not be taken to the scenes of crime, except at the explicit request of the Police;
- Visits will not take place to the scenes of road traffic accidents;
- A visit must add value to the process;
- In general, nurses (notably health visitors) are the health professional with most expertise in visiting and assessing children within their homes; and
- Safety is paramount, and health professionals will not attend the homes of families where a child died under suspicious circumstances on their own.
When a visit is agreed, it will be undertaken by the SUDIC Paediatrician/Team and/or other nominated health professional, usually within 72 hours after the child's death, during normal working hours. The purpose of the visit is not forensic, and it is recognised that potential evidence will have been removed from the scene by Police by the time a visit takes place.
Visits will not usually be undertaken by the SUDIC Paediatrician (or member of a SUDIC Team) alone, and one of the following options will be utilised, by negotiation, on a case by case basis, for example:
- A visit alongside the Police, who often visit the site of death again the following day;
- A visit alongside the primary health care team, providing the opportunity for support to the family from a professional whom they already know.
The purpose of the visit is to provide the information that may enable identification of the cause of death, and will include meeting and information gathering with parents/carers, and inspection of the place of death.
7. Discussion at 5 to 7 Days
The SUDIC Paediatrician/Team will, in all cases, initiate multi-agency discussion (by telephone) within 5-7 working days, to review and update information. This discussion will include:
- The pathologist undertaking the post-mortem;
- The Police;
- Children's Social Care;
- Consultant Paediatrician (or Consultant in Emergency Medicine) involved in the process;
- Other relevant health care professionals involved in the care of the child before death or in the period surrounding death.
At this point, the SUDIC Paediatrician/Team should consider preparing a report for the Coroner.
8. Provision of 28 Day Report to the Coroner
All information collected by those involved in responding to the child's death will be collated into a report for the Coroner by the SUDIC Paediatrician/Team.
This report should be sent to the Coroner by 28 days after death unless some of the crucial information is not yet available.
The 28 day report should include a review of records from other agencies (e.g. Education, Children's Social Care). The 28 day report should therefore highlight where relevant information is held by other agencies. The Coroner may then commission reports directly from those agencies if he deems it necessary.
9. Case Discussion Meeting
Once the final results of the post-mortem are available, a case discussion meeting to discuss of the circumstance of death will be held. The meeting will be convened and chaired by the SUDIC Paediatrician/Team.
The purpose of the case discussion is:
- To share information to identify the cause of death and/or those factors which may have contributed to the death;
- To plan future care for the family;
- To identify potential lessons;
- To inform the inquest.
The timing of the meeting will be determined by the availability of the final post-mortem results, and should take place as soon as possible thereafter, normally within 12 weeks. If the final post-mortem results are delayed beyond 12 weeks, an interim discussion should be considered.
The case discussion should involve those who provided care to the child and family before death, and those involved in investigating the death. This will be determined by the age of the child and the circumstances of the death, and may possibly include:
- Midwife, Health visitor or school nurse;
- Paediatrician and other relevant clinicians;
- Senior Investigating Police Officer;
- Social worker;
- Others as appropriate.
The case discussion should be informed by the case records and other information regarding the child and other relevant family members.
The location for the case discussion should take into account the need to facilitate involvement of the GP and Primary Care Team.
The outcomes from the meeting should be recorded and will include:
- An discussion of the possibility that abuse or neglect caused or contributed to the death;
- An agreement about how detailed information about the cause of the child's death will be shared, and by whom, with the parents, and those who will offer agency support (see Section 10, Keeping Parents Informed). The hospital paediatrician will usually undertake this role, but in cases where the child has been transferred between hospitals or wards, this may require clarification);
- An agreed record of the case discussion meeting and all reports should be sent to the Coroner, to take into consideration in the conduct of the inquest and in the cause of death notified to the Registrar of Births and Deaths;
- The record of the case discussions and the record of the core data set should also be made available to the relevant Child Death Overview Panel - see Child Death Reviews Procedure.
Consideration should be given to a further case discussion when the inquest is complete.
10. Keeping Parents Informed
Current practice is for the Coroner's Officer or Police Family Liaison Officer to feed back the post mortem results to the family. This should continue.
In addition, it is good practice for the Paediatrician involved in the process when the child was brought in to the hospital (or the Consultant in Emergency Medicine) to keep parents informed about the findings of the post mortem. The consultant will determine the appropriate times to meet with the parents depending upon when the preliminary and final post-mortem results become available.
Where there is concern that the death is suspicious, a decision as to what information is shared and how it is disclosed to parents should be determined by the Senior Investigating Police Officer.