8.3 Child Death Review Guideline

last updated July 2020


Glossary of Terms / Abbreviations





Child Death Overview Panel


Child Death Review

CDR Partners

All agencies involved in the Child Death Review Process


Child Death Review Meeting


Child Health Information Service


Care of the next infant



Crown Prosecution Service



Local centralised databased which collates notifications and paperwork pertaining to the Child death review process

Emergency Department

Preferred name of an Accident and Emergency (A&E)



Police Family Liaison Officer

Forensic Pathologist

Home Office Pathologist (see below)


A fold of membrane that limits the movement of an

organ. In these circumstances it means the upper lip

unless otherwise specified. It may also be applied to the

tongue or foreskin of the penis.

Home Office Pathologist

A pathologist with special training as a forensic

pathologist who is on the Home Office list of accredited

forensic pathologists.


For the purposes of this document, an individual of less than 2 years of age.


Joint Agency Response


Medical Cause of Death Certificate (see section 2.2)


National Child Mortality Database


Perinatal Mortality Review Tool


Sudden Infant Death Syndrome


Senior Investigating Officer (Police)


Sudden Unexplained Death in Childhood

SUDC Paediatrician

Equivalent to the "Designated Paediatrician for Unexpected Deaths" described in Working together.


Sudden Unexplained Death in Infancy / Childhood



The death of any child is a tragedy. Every parent has a right to have such an event properly investigated. The vast majority of sudden child deaths are the result of natural causes. However, all child deaths need to be appropriately investigated to exclude homicide, to reassure the family and ensure that future children are protected, and to satisfy wider public concerns.


This guideline is provided to support staff working within Buckinghamshire Healthcare NHS Trust following the death of a child or young person. It aims to give an overview of the whole Child Death Review Process and to offer specific operational guidance on the management of child deaths.


A child is defined as anyone who has not yet reached their 18th birthday. ‘Children’ therefore means ‘children and young people’ throughout. The fact that a child has reached 16 years of age, is living independently or is in further education, is a member of the armed forces, is in hospital, in prison or in a Young Offenders’ Institution, does not change his or her status or entitlement to services or protection under the Children Act.


This protocol does not apply to stillbirths, unless the stillbirth occurs within the community without any medical interventions and a doctor is not able to issue a death certificate.


This document provides the framework for a comprehensive and sensitive enquiry aimed at establishing the cause of, and factors contributing to, all deaths in all children under 18 years, with particular attention to the management of sudden, unexpected deaths. This guidance is not intended to be prescriptive, but endeavours to provide advice to practitioners who are confronted with these tragic circumstances.


Professionals need to strike a balance between the sensitivities of handling the bereaved parents and securing and preserving evidence, which may aid them in arriving at an understanding of why a child has died.


When dealing with an unexpected or unexplained child death, all agencies need to follow five common, equally important, principles:

  • A sensitive, open-minded and balanced approach
  • An inter-agency response
  • Sharing of information
  • An appropriate response to the circumstances
  • Preservation of evidence



Management of Child Deaths and Child Death Reviews (CDR)

1 - Overview of the Child Death Review Process

1.1 Introduction

The purposes of the child death review process are

  1. To establish, where possible, cause(s) of death
  2. To identify any potential contributory factors
  3. To provide ongoing support to the family
  4. To learn lessons in order to reduce the risks of future child deaths


There are two interrelated processes for reviewing child deaths:

  1. A local, multiagency agency review by an appropriate group of key professionals
  2. An overview of all child deaths (under 18 years) in the safeguarding partnership area(s)

  The child death review process is outlined below:

The following guidance divides this process into its constituent parts.

1.2 Immediate decision making and notifications

A number of decisions need to be made by professionals in the hours immediately following the death of a child. These include:

  • how best to support the family
  • whether the death meets the criteria for a Joint Agency Response
  • whether a death certificate can be issued
  • whether a referral to the coroner is required
  • whether the death meets the criteria for an NHS serious incident investigation


A number of notifications should also be made: to the child’s GP and other professionals; to the Child Health Information System; and the relevant Child Death Review partners (as a minimum police and social care) and the Child Death Overview Panel (CDOP).

1.3 Investigation and Information gathering

After the above a number of investigations may then follow. These include:

  • Coronial investigation
  • Joint Agency Response
  • NHS Serious Incident Investigation


Post-mortem examinations may be required in a number of cases. Which investigations are necessary will vary depending on the circumstances of the individual case. They may run in parallel, and timeframes will vary greatly from case to case.

1.4 Child Death Review Meeting (CDRM)

Although investigations following the death of a child will vary, every child’s death should be discussed at a Child Death Review Meeting. This is the multi-professional meeting attended by professionals directly involved in the care of that child during life and those involved in the investigation after death.


The nature of this meeting will vary according to the circumstances of the child’s death and the practitioners involved.

1.5 Review of child deaths at a Child Death Overview Panel (CDOP)

Child Death Overview Panels (CDOPs) are responsible for reviewing information on all child deaths. Information from the above investigations are fed into the CDOP for final review. In Buckinghamshire there are two CDOPs, one for Milton Keynes and; one for the rest of Buckinghamshire. The CDOP for the Buckinghamshire contains representation from the clinical commissioning group, Social Care, Thames Valley Police, the Buckinghamshire coroner’s office, Public Health, South Central Ambulance Service, Midwifery and Education. In addition the paediatric liaison nurse and Designated Doctor for Child Death Reviews in Bucks also attend.


In light of the 2018 guidance of child death reviews Buckinghamshire CDOP joins with Oxfordshire CDOP on a regular basis to gather information about common themes and learning.


Child death review processes have been mandatory since April 2008.

1.6 Support for the family

Supporting and engaging the family who have lost a child is of prime importance throughout the whole child death review process. Recognizing the complexity of the process, and the different emotional responses that bereavement can bring, families should be given a single, named point of contact, i.e. the “key worker”, for information on the processes following their child's death, and who can signpost them to sources of support.


Immediate Decision Making and Notifications

2.1 Immediate Actions

Multiagency discussion and planning is required within the first few hours following notification of a child’s death. Necessary discussions may be face-to-face or by telephone and should engage the following professionals:

  • The Medical Examiner, once the national system is introduced;
  • Other professionals as appropriate; for example:
    • the on-call paediatrician
    • police
    • duty social worker

Information about the circumstances of the child’s death and medical and social background should be sought to aid with the following:

  1. Identifying how best to support the family
  2. Issuing a Medical Cause of Death Certificate (MCCD). If this is not possible, consider whether the death should be referred to the coroner. (see section 2.2 below)
  3. Deciding whether a Joint Agency Response is required (see section 3.3 below)
  4. Identifying issues relating to health care or service delivery
  5. Determining actions to ensure the health and safety of others (e.g. family or community members, other patients and staff)

In all deaths, these discussions should be recorded on a relevant proforma (see Appendix I). The outcome of these discussions should also be fed back to the family.

2.2 Issuing an MCCD or referral to the coroner

  • Cause of death for most children is known and an MCCD can be issued shortly after death.
    • Detailed guidance can be found HERE.
    • Two versions of the death certificate exist
      • a neonatal certificate (up to 28 days)
      • the standard certificate.
    • In deaths of children with pre-existing complex medical conditions, correct wording of the death certificate may need to be discussed with the specialist team.
    • If it is not possible to sign the MCCD then the case should be referred to the coroner.
    • The Chief Coroner has issued guidance on which deaths should be reported to the coroner (see section 3.2 below). If there is any uncertainty over whether a referral is necessary, the attending doctor should contact the coroner’s office to discuss.


2.3 The Post-Mortem Examination

A post mortem examination is sometimes required as part of a coronial investigation. If a coroner requires a post mortem examination parental consent is not required and parents cannot refuse the examination.


In cases where a death certificate can be issued a hospital post mortem examination (PM) may still provide important information as to why a child has died. It is therefore important to explore the issue with the family at the time of death, even in cases where the coroner does not require a PM.

2.4 Informing the Child Death Overview Panel

This should by electronically filling out a notification form. This is done via the eCDOP website using the “Submit Notification form (see right):

2.5 Other notifications

The following people should also be notified within 24 hours (or the next working day) of the child’s death:

  • General Practitioner; inform the GP of the fact and circumstances of the death, so that the GP is able to support the family;
  • Other professionals, as appropriate; community midwives, health visitor, school nurse, hospital/community medical team;




Investigating and Information Gathering

3.1 Introduction

The nature of the investigation(s) vary with individual circumstances. They may include:

  • A Coronial Investigation
  • A Joint Agency Response
  • A Serious Incident investigation
  • A Safeguarding Practice Review (Formerly known as Serious Case reviews)


For all deaths essential information regarding demographics, circumstances of death and background medical history should be submitted to CDOP via the Reporting Form (Previously form B).

3.2 Coronial Investigation

Informing the Coroner

The coroner’s office must be informed of all ‘unexpected’ deaths via  01494 475505 (call Thames Valley Police on 101 out of hours). Once death has been declared, the coroner assumes immediate responsibility for the body. Samples may be taken post mortem as outlined in Appendix IV.


Anyone can refer a death to the coroner for investigation. Reasons for referral are as follows:

  • the cause of death is unknown
  • the deceased was not seen by the certifying doctor either after death or within 14 days before death
  • the death was violent or suspicious
  • the death was unnatural
  • the death may be due to an accident (whenever it occurred)
  • the death may be due to self-neglect or neglect by others
  • the death may be due to an abortion
  • the death occurred during an operation or before recovery from the effects of an anaesthetic
  • the death may be a suicide
  • the death occurred during or shortly after detention in police or prison custody
  • the death occurred while the deceased was subject to compulsory detention under the Mental Health Act or a Deprivation of Liberty Safeguards authorisation (DoLS)
  • Deaths that may be lined to medical treatment, surgery or anaesthetic
  • for any other concerning



They may order a post-mortem (PM) examination, if necessary. Following the PM, the body of the child is usually promptly released back to their family for the death to be registered and funeral arrangements to be made. Release may however be later if organs have been taken for analysis, or if a second independent post-mortem examination is required.

 Not all deaths reported to the coroner proceed to inquest although most unexplained deaths of children do. The inquest aims to determine the identity of the person that died and how, when and where they came by their death. The coroner will examine the evidence and, commonly without a jury, record the answers to the questions listed on a public document called the Record of Inquest. The details of the coroner’s findings are forwarded to the local registrar.


All agencies holding pertinent information are under a duty to disclose such information.


The family should be informed early on of the coroner’s involvement; the need for and timing of a post-mortem examination; their right to be represented at the examination should they so wish; whether an investigation or inquest has been opened so that they may attend the inquest opening; and the dates of any investigation reviews, pre-inquest reviews and the inquest itself. Once the jurisdiction of the coroner is engaged, the coroner’s officer is the main point of contact with the family for matters relating to the coronial process.


3.3 Joint Agency Response (JAR)

All deceased children that meet the criteria for a JAR should be transferred to the nearest appropriate Emergency Department to enable the JAR to be triggered.


A Joint Agency Response should be triggered if a child’s death:

  • is or could be due to external causes;
  • is sudden and there is no immediately apparent cause
    • (including Sudden Unexplained Death in Infancy/ Childhood);
  • occurs in custody, or where the child was detained under the Mental Health Act;
  • suspicion of unnatural causes (see below)
  • in the case of a stillbirth with no healthcare professional in attendance


In any of these circumstances, the on-call paediatrician at Stoke Mandeville Hospital, police investigator, and duty social worker should be contacted immediately so as to initiate the joint agency response.


A Joint Agency Response should also be triggered if such children are brought to hospital near death, are successfully resuscitated, but are expected to die in the following days. This enables an accurate history of events to be taken and, if necessary, a ‘scene of collapse’ visit to occur. Appropriate clinical investigations should also be performed in such cases SEE APPENDIX IV


A lead health professional should be assigned. This will usually be the on call paediatrician. This person will ensure that all health responses are implemented, and be responsible for on-going liaison with the police and other agencies.


3.3.6 The flow chart above (fig. 4) sets out the sequence of events that should unfold in a Joint Agency Response. A Joint Agency Response can be divided into three separate phases


  1. Immediate response (within a few hours)
    1. Caring for the Family
    2. Initial History taking
    3. Initial examination
    4. Initial laboratory investigations / samples
    5. Immediate Information sharing / planning
  2. Early Response (within a few days)
    1. Ongoing information gathering
    2. Home visit by police
    3. Initial Case Discussion Meeting
    4. Post mortem examination
  3. Late Response
    1. Child Death Review Meeting (See Section 4)

Immediate Response

Normally following an unexpected death, a child will be transferred by the ambulance service to Stoke Mandeville Hospital. The emergency providers attending the scene should assess the child and, unless it is clearly inappropriate, should attempt resuscitation and transfer the child and family to hospital. The child should never be taken straight to the mortuary unless directed by the police in consultation with the coroner. In such cases the police are responsible for notifying the consultant paediatrician on-call.


On arrival at hospital, a member of the nursing staff will be allocated to the family. On arrival at the A&E department the consultant paediatrician and/or senior doctor in A&E should be informed. Immediate responsibility for informing and providing appropriate care and support of the family rests with the on-call paediatric team. Resuscitation should continue as appropriate and any decision to stop will be made by an experienced medical practitioner with input from other members of the resuscitation team and in consultation with the family. As soon as practicable after arrival at a hospital, the child should be examined by the consultant paediatrician or delegated senior paediatrician on-call.


When the child is pronounced dead, the paediatric or A&E consultant or delegated senior clinician should inform the parents, having first reviewed all the available information.  S/he should explain future police and coronial involvement, including the coroner’s authority to order a post-mortem examination.  This may involve taking particular tissue blocks and slides to ascertain the cause of death.

Caring for the Family

Initial bereavement support will be provided by hospital staff. This is a difficult time for everyone. The time spent with the family may be brief but actions will greatly influence how the family deals with the bereavement for a long time afterwards. Remember that families are in the first stages of grief. They may be shocked, numb, withdrawn, angry or hysterical. Every effort should be made to conduct discussions in a private and sympathetic environment away from interruptions.


Communication should be clear, sensitive and honest. Parents should be treated with compassion, respect and dignity.


Where parents do not understand and/or speak English well, an independent interpreter should be called – one can be arranged via switch board. The interpreter should not normally be a family member. However, urgent information about the child could be sought from a family member whilst awaiting an interpreter to arrive.


Staff caring for families after a child’s death should be offered support through a formal debrief system and counselling via the Workplace Health Department, as appropriate.


Ongoing bereavement care is available from a range of agencies. Further details can be found in Appendix II.


For lactating mothers please consider prescribing Cabergoline 250 mcg every 12 hours for 2 days (tablets stocked by pharmacy) to supress lactation. NB Contraindicated in hypertension including pre-eclampsia

Initial History Taking

Most of the medical and social history will be obtained during the initial discussion with the parents in the A&E Department. This is supplemented by information obtained at the home visit. All professionals should record history and background information given by parents/carers in as much detail as possible.


It is crucial that under no circumstances should professionals challenge or make comment on the history given by a parent/carer – if challenged or a comment is made parents/carers may form the impression that their account is not believed and may subsequently change their story. This could hinder any police investigation


If there are other children, enquire about their whereabouts and who is caring for them. A surviving twin should automatically be offered admission for monitoring and investigation.

Immediate  Information Sharing / Planning

A Joint Agency Response for children who normally reside within Bucks and who die in Bucks will be coordinated by the on-call paediatric team at Stoke Mandeville Hospital. These deaths should be notified to the on-call paediatrician by telephone. The consultant paediatrician on-call is responsible for instigating the Joint Agency Response and must ensure that police, social care and other appropriate agencies have been notified.


For children who reside in Bucks who have died at the John Radcliffe hospital in Oxford the paediatric team at Stoke Mandeville Hospital will coordinate the Joint Agency Response. These deaths should be notified in the first instance to the on-call paediatrician at Stoke Mandeville Hospital, who will then liaise with the Designated Doctor for Child Death Reviews (or in their absence the Named Doctor for Safeguarding).


For children who reside in Bucks who have died at a tertiary centre other than Oxford (e.g. GOSH, Birmingham etc), the initial response should be dealt with by the team within that centre. The paediatricians at Stoke Mandeville do not coordinate the investigation, but may be called upon to attend meetings (e.g. case discussion / case review meetings) at the tertiary centre. They may also be called upon to submit a “reporting form” (Previously a “Form B”) about the child to the Bucks CDOP.


For children dying within Bucks who normally reside elsewhere, the paediatric team will coordinate a Joint Agency Response as for a Bucks child, submitting information to the child’s local CDOP as appropriate. The exception to this would be a child from Oxfordshire. These cases should be notified to, the SUDC Paediatrician at the John Radcliffe or to the CDOP administrator for Oxfordshire (both available via the John Radcliffe Switchboard).


If there is any uncertainty about whether a Joint Agency Response is required, or who should convene one, it is imperative that it be discussed with the SUDC paediatrician as a matter of urgency. If the SUDC paediatrician is on leave then this should be discussed with the Named Doctor for Child Protection.


Early contact and discussion between key agencies is essential. Discussion should focus on whether the death may have been caused by abuse or neglect. In such cases the safety of siblings must be considered. Consideration should be given to securing the scene where the child died. Discussion about the need for a home/scene visit should take place early on between the police officer and the on-call paediatrician, enabling the prompt recovery of evidence that otherwise could be lost. A home visit will almost always be required in deaths under the age of 2 years. Paediatricians do not currently participate in home visits. The photographs from home visits can be shared and discussed by the team during the Joint Agency Response meeting.


Contact with police and social work should be clearly documented in the notes. No professional should assume they have been contacted. Repeated calls are better than none at all. 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.


On receiving notification of an unexpected child death, a senior police officer will be designated as the Senior Investigating Officer (SIO). It is important to stress to the family that the involvement of the police is routine and does not assume suspicion. However, staff need to be aware that on occasions, in suspicious circumstances, the early arrest of the parents/carers may be essential in order to secure and preserve evidence as part of an investigation.

Initial Laboratory Investigations & Samples

Laboratory investigations should be performed seeking to establish the cause of death. If these have not been taken prior to death they may be taken in consultation with the coroner.


A set of investigations has been agreed with the coroner and these should be taken while the child is still in A&E. Taking specimens in A&E will prevent delays which may affect value of the specimens. The full list can be found in Appendix IV .  It may not be appropriate to obtain all samples in all cases. For example, older children who have died following a short febrile illness may not require a full metabolic workup.


Forensic considerations

  • Ensure you have permission of the coroner to take samples not outlined within Appendix IV.
  • Document all samples taken, label and ensure an unbroken ‘chain of evidence’. This may mean handing samples to a police officer directly, or having the laboratory technician sign on receiving them in the laboratory.
  • Samples given to police or coroner’s officer must be signed for.
  • Record the site from which all samples were taken.


All findings and interventions, including information given to the family, should be carefully documented in the hospital notes. Where appropriate the Sudden Unexpected Death Proforma (Appendix III) should be used as an aide memoire for the information gathering.


If required, a skeletal survey will be done as part of the post mortem examination. This will be arranged at Oxford by the Paediatric Pathologist.


Clothing can be left on the child. If removed it should be placed in a labelled specimen bag. Any other items, such as bedding, brought in with the child should also be placed in labelled specimen bags to be given to the pathologist.


No items should be returned to the parents without consultation with the paediatrician, police officer involved and the coroner.


Retention of any personal items must be documented and when handed over to the police or pathologist including date, time and details of who has taken responsibility for such items recorded in medical records, i.e. Police Officer’s identification number, role and place of work.


In the case of a baby, a clean nappy should be provided and the soiled nappy retained and sealed in a labelled bag (double bagged) and passed to the pathologist. Leave all tubes, cannulae, drains and catheters in situ unless removal has been agreed by the coroner.


In seeking to clarify the cause of death and the facts which contributed to it, the paediatrician should document:

  • The detailed history
  • A full account of any resuscitation and any interventions of investigations carried out
  • An account by the carer, including narrative, of the events leading to the death
  • A body chart documenting the examination findings and any post-mortem changes
  • A list of the investigations already performed


Ideally this information should be captured using the SUDC proforma as set out in Appendix III.


Two copies of the Accident and Emergency documentation, including the SUDC proforma should be made. One should remain with the child and the other should be kept in the child’s notes.  Copies of all photographs and X-rays should be made for the use of the coroner.


A copy of the Child Death Checklist (Appendix V) should be filled out and stapled to the inside front cover of the child’s admission pack. This needs to be completed in a timely fashion and uploaded with the rest of the note onto EVOLVE.

Factors That Suggest a Death May be Suspicious

There are certain factors in the history or examination of the child, which may give rise to concern about the circumstances surrounding the death. If any such factors are identified, it is important that the information is documented, the SIO notified immediately and shared with senior colleagues and relevant professionals in other key agencies involved in the investigation.


The following factors should be considered in the history. This list is intended only as a guide and is not exhaustive.

  • Previous child deaths
    1. However, there are some rare genetic disorders, which can cause multiple cot deaths within a single family. In such cases, an extended family history should be obtained and the involvement of a clinical geneticist may be helpful.
  • Previous Child in Need / Child Protection concerns about this child or their siblings
  • Delay in seeking help without adequate explanation
  • Inconsistent Explanations:
    1. The account given by the parents/carers should be documented verbatim. Any inconsistencies in the story given on different occasions should arouse suspicions, although it is important to bear in mind that some inconsistencies may occur as a result of the shock and trauma caused by the death.
    2. Explanations as to how the injuries occurred should be placed under detailed scrutiny when:
      1. The explanation changes with time or questioning; or
      2. The ‘accident’ was beyond the child’s development
  • Evidence of parental drug/alcohol abuse
  • Evidence of significant parental mental health problems
Examination of the child

An examination of the child should seek to establish any unexplained injury, including (taking into consideration the resuscitation process):

  • Any evidence of major bleeding or injury (cranial, bony, visceral or soft tissue) is highly suspicious unless proved otherwise
  • The presence or otherwise of unexplained bruising/burns/bite marks including
    1. Multiple bruises to the face, ears, limbs or the trunk
    2. Finger print bruises and linear bruises are highly suspicious
    3. Torn frenulum e.g. due to force feeding
    4. Petechial haemorrhages may or may not be present with suffocation and its absence is not conclusive either way but their presence should be noted
    5. Blood around mouth and nose
      1. a small amount of bleeding around the mouth and nose may be normal
      2. A lot of blood however should be treated with suspicion.
  • Some froth around the mouth may be normal.
  • Evidence of neglect
    1. Observations about the condition of the accommodation, general hygiene and cleanliness, the availability of food, adequacy of clothing and bedding and temperature of the environment in which the child is found are important. This will assist in determining whether there may be any underlying neglect issues involved. Historical information from a range of agencies should be taken into consideration about persistent concerns and adequacy of care provided to children, or adequacy of self-care in parents should also raise suspicion about underlying neglect issues.
  • Shaking injuries
    1. These injuries present with non-specific symptoms ranging from apnoea, brief resolved unexplained event (BRUE), seizures, unexplained drowsiness and/or ‘sudden loss of consciousness’. Diagnosis requires a high index of suspicion.
    2. Photographs of the retina for signs of haemorrhage may prove invaluable.
    3. During resuscitation, screening test for blood clotting disorders should be carried out promptly as brain injuries will eventually cause a similar effect.
  • Concealed births
    1. These types of deaths normally involve very young or mothers with serious mental illness giving birth ‘unknowingly’ until the onset of labour or in secret. A crucial part of any such investigation will be to establish whether the child ever had independent existence from the mother. In such cases prosecutions may not always be appropriate and the CPS should be consulted where there are concerns that the mother did not fully understand the nature and quality of her actions.


A photographic record should be made of all injuries at the earliest opportunity. This may require a police photographer.

Early Response (within a few days)

The Home or Scene Visit

For all children less than 2 years of age who have died suddenly and unexpectedly, a home visit should be undertaken within 24hrs (usually the same day). For older children the need for a home visit should be discussed between the police and the paediatric team. The home visit is usually conducted by the police. The home visit provides an opportunity to take a more careful history, to inspect the death scene and to try and alleviate some of the family’s concerns.


The purposes of the home or scene visit are to:

  1. Review the history taken in ED
  2. Evaluate the environment where the child died
  3. Support the family
  4. Update the family on the investigation. The discussion with parents about the details of the post-mortem examination should be done in conjunction with coroner’s officers.


Where the location of the death is different to the home address of the child, an additional visit to the home address may be arranged if deemed necessary. Consideration should be given as to which professionals should attend the visit. Normally this will be the senior investigating officer. Where possible a member of the primary care team, or some other professional known to the family may also attend. There may be situations where, for pragmatic reasons, or because of the nature of the death a joint visit is not possible or appropriate, or where the police need to visit the scene of death early to gather forensic evidence.

Ongoing Information Sharing

Further information will need to be gathered to support the investigation into the cause and circumstances of death. All practitioners play a role in this and must be prepared to share information with other members of the multi-agency team.


The senior investigating officer (SIO) and on-call paediatrician should agree who will take the lead for collating information and sharing this with the coroner. Information will need to be gathered through a process of history taking, which may require more than one interview with the parents.


As far as possible, repeated questioning by different professionals should be avoided and parents interviewed jointly by police and health staff where appropriate. Information should be gathered from the primary care team and all other professionals who may know the child or family, including The Midwife, Health Visitor, School Nurse, social care and education where appropriate. All relevant records should be retrieved and reviewed by a lead professional in each agency.

The Post-Mortem Examination

Generally most post-mortem examinations will be performed at the John Radcliffe Hospital in Oxford. If any concerns have been raised about the possibility of neglect or abuse having contributed to the child’s death, or the pathologist becomes concerned about such a possibility during the course of the post-mortem examination, the paediatric pathologist should be accompanied by a forensic pathologist and a joint post-mortem examination protocol should be followed with the attendance of a senior investigating police officer. 


Prior to commencing the post-mortem examination, the pathologist should be given a full written briefing on the history and the physical findings at presentation, and the findings of the death scene investigation. The senior investigating officer will ensure child’s ‘red book’ is secured and shared with the pathologist.


Any photographs or video recordings of the child or the scene should be made available to the pathologist. The pathologist should also be provided with a report and/or images from the radiographer for any radiological investigations. If required, skeletal surveys are performed at the time of the post mortem examination.


The coroner should be provided with a copy of the history proforma. Where possible there should be an information sharing discussion between the consultant paediatrician and the pathologist before the post-mortem examination to identify outstanding issues and to ensure accurate understanding of information.


If the paediatrician has arranged any laboratory investigations before death, the pathologist and the coroner should be informed prior to the post-mortem examination, and the results made available as soon as possible.  


Following the post-mortem examination, there should be a further discussion between the paediatrician, the pathologist, the senior investigating officer (SIO), a lead representative from children’s social care and the coroner’s officer to review any preliminary findings and decide on any further investigations required. If initial post-mortem examination findings are shared with the family, this MUST be done with the coroner’s consent.


The final report of the post-mortem examination should be sent to the Coroner immediately once the final result is known. With the prior consent of the Coroner, a copy of the post-mortem examination report will also be sent simultaneously to the responsible paediatrician.

The Joint Agency Response (JAR) Meeting

The on-call Paediatrician or a deputy will convene a Joint Agency Response Meeting. This meeting will take place within 2 working days of an unexpected death. It must be convened prior to a post mortem taking place so that information gathered at this meeting can be shared with the coroner to aid his investigation.


In cases where the process is interrupted by a weekend it may be necessary to hold this meeting early in the following week. This is in order that agencies which may hold information about the child (e.g. GP, Health Visitor, community midwife, ambulance crew etc) will be able to attend. In these cases it is critical that police, social work and the on-call paediatrician share information over the weekend period so that any information which comes to light over the weekend can be acted upon promptly. In other words the JAR Meeting should not be viewed as the first opportunity to share information and if an agency becomes concerned it should share those concerns immediately.


The Joint Agency Response Meeting may include representation from:

  • Health
    • The on-call Paediatrician / SUDC Paediatrician
    • Senior members of the children’s nursing team
    • Ambulance service / A&E staff / Intensive care / Anaesthetists
    • The named health visitor, children’s community nurse or school nurse
    • The community midwife
    • The general practitioner
    • Children’s / Adult (for parents) Mental Health teams
  • Social Work - The children’s social care team manager or appropriate deputy
  • Police – The Senior Investigating Officer or an appropriate deputy
  • Other contributors
    • Coroner’s officer
    • Education (where the child was attending school or nursery)
    • The named professionals for Child Protection
    • Mental health professionals (CPN or consultant psychiatrist)
    • Any other agency known to the child / family e.g. drug/alcohol services.


The meeting should be minuted by one of the paediatric secretaries. A draft agenda for the meeting including specific areas to be covered in the discussion can be found in Appendix VI.


The purposes of this meeting are:

  • Information Sharing and Analysis
    • Each agency will share information regarding circumstances of the child’s death and any background information they hold
    • Consider any evidence of child abuse, neglect or poor parental care.
    • To collate all relevant information to share with the pathologist.
    • To identify factors which may have contributed to the Child’s Death
  • Investigation Planning
    • To determine which professional/agency will lead the multi-agency investigation.
    • To plan and determine the process of the investigation. Each of the following questions must be asked and their answers recorded.
      • Is the death suspicious, requiring a police investigation?
      • Does the death constitute a serious untoward incident?
      • Is a Safeguarding Practice Review (previously known as a Serious Case Review) required?
    • Management Planning
      • To ensure a coordinated bereavement care plan for the family. This should include nominating a professional to share the results of the post mortem examination.
      • To enable consideration of any child safeguarding risks to siblings/any other children living in the household, and to consider the need for child protection procedures.
      • To discuss any need for action in respect of other children in the household or family (e.g. health overview).


If child protection concerns are identified when the information is shared this meeting will become a strategy meeting under child protection procedures, and the director of children’s’ social care or equivalent will be notified. 


Approved minutes will be shared with each of the attendees, the coroner’s office, the SUDC paediatrician and the Child Death Overview Panel. They should be distributed within 1 week of the meeting for comments / amendment. The minutes should then be saved as part of the child’s medical record.


Parental consent is not required for this information to be passed to the designated paediatrician and CDOP. However it should only be shared with those who need to know governed by the Caldicott Principles, the Data Protection Act and Working Together.

Agency Report Form (Previously Form B)

Following the JAR meeting it is the responsibility of the on-call paediatrician to ensure that an Agency Report Form is submitted to CDOP and that any professionals who have not contributed to the JAR Meeting are identified. They should be invited to complete an independent agency report form on CDOP. This can be coordinated through the CDOP admin team. The CDOP admin team will send invitation to fill out the reporting form via email. The reporting form should be completed online within 28 days of the child’s death.

DATIX and Serious Incidents

All unexpected deaths should be reported via the DATIX electronic incident reporting system. The lead handler for these incidents is the SUDC paediatrician. It is the responsibility of the consultant paediatrician to ensure that this happens.

The Healthcare Safety Investigations Branch

Healthcare Safety Investigations Branch (HSIB) carries out independent investigations into safety concerns within NHS funded care in England. It aims to be thorough, independent and impartial in its approach without apportioning blame or liability.


Separately, HSIB investigate NHS Serious Incident Investigation cases of

  • intrapartum stillbirth
  • early neonatal deaths
  • severe brain injuries from 37 weeks gestation


These investigations will continue to be characterized by a focus on learning and not attributing blame, and the involvement of the family is a key priority.

Co-ordination across investigations

It is easy for families to become lost in the parallel investigations following their child’s death. Effective co-ordination and good communication are vital to avoid additional distress to bereaved parents.


A “key worker” should be assigned to every bereaved family, to act as a single point of contact in relation to the child death review process.


In deaths where there is more than one investigation, NHS trusts should appoint a “case manager” to have oversight of procedures: ensuring that those involved are objective (e.g. through engaging the Patient Advice and Liaison Service), have an understanding of statutory requirements, follow appropriate timescales, ensure parents have an opportunity to input into the process and establish how they would like to receive feedback. This is distinct from the key worker, who acts as an ongoing single point of contact for families.




The Child death review Meeting (CDRM)

4.1 Introduction

The 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. It was previously known as a final case discussion meeting


The nature of this meeting will vary according to the circumstances of the child’s death and the practitioners involved.

Circumstances of death

CDRM Format

Sudden unexpected death

Final case discussion involving health, police and social care

Expected death in PICU

Morbidity and mortality meeting in PICU, with input from local team if appropriate

Death in Neonatal Unit

Perinatal mortality review (PMRT) Meeting

Expected death for child with life limiting illness

Morbidity and mortality meeting

Examples of child death review meetings


The CDRM should be

  • flexible and proportionate
  • focused on local learning
  • Undertaken for all Deaths (expected and unexpected)


It may be appropriate for the review to be quite brief or for the meeting to discuss one child or several children. In every case, the Analysis Form (Previously form C) should be drafted at the CDRM and then sent to the relevant CDOP.

4.2 Aims

In all cases, the aims of the CDRM are to:

  • review the background history, treatment, and outcomes of investigations, to determine, as far as is possible, the likely cause of death
  • ascertain contributory and modifiable factors in the following areas
    • service delivery
    • child
    • social and physical environment
  • describe learning arising from the death and associated actions
  • review the support provided to the family
  • ensure that the family are provided with
    • the outcomes of any investigation into their child’s death
    • an explanation of why their child died along with any learning from the review meeting. If the family’s first language is not English this may require a face to face meeting with a translator.
  • ensure that CDOP and, where appropriate, the coroner is informed of the outcomes of any investigation into the child’s death
  • review the support provided to staff involved in the care of the child.


4.3 Attendees and Chair

It is the responsibility of the organisation responsible for the declaration of death to arrange the CDRM. The exception to this is when a Joint Agency Response has occurred, in which case responsibility defaults to the lead health professional.

Each child’s death requires unique consideration and where possible, should engage professionals across the pathway of care. The following professionals may be invited, depending on their ability to contribute meaningfully to a discussion on the circumstances of the child’s death:

  • hospital or community healthcare staff involved with the child at the end of his/her life, and those known to the family prior to this event;
  • pathologist, if a post-mortem examination has taken place
  • other professional peers from relevant hospital departments and community services;
  • patient safety team if a serious incident investigation has taken place;
  • coroner’s officer, if the case has been referred to the coroner;
  • senior investigating police officer, if there is a Joint Agency Response; or
  • other practitioners for example social work, ambulance and fire services, primary care clinicians, school nurse, head teacher, representatives from voluntary organisations.

NHS Trusts should note that, where practically possible, children’s deaths should be discussed at an individualized meeting, and that matters of morbidity should be considered separately. It is only through such a comprehensive approach that the contributory factors to death can be understood. (See case examples at Appendix 1 for further illustration). If certain professionals are unable to attend, they might be invited to submit a report to the meeting.


The CDRM should be chaired by the designated doctor for child death reviews, unless he was directly involved in the case. At the beginning of each meeting the Chair should inquire as to conflicts of interest among the attendees. In rare cases, it may be necessary to seek a chair external to the organisation; for example, when trust has broken down between the family and health care team in the organisation where death was declared. The designated doctor for child deaths might advise in such circumstances.

4.4 Location and Timing

In general, children who die in hospital should be discussed within the department where the child died, and considered an integral part of wider clinical governance processes.

Children who die in the community might be discussed at the local GP surgery, and children who die in a hospice discussed in that centre. However, the location of the meeting might also be informed by practical considerations relating to where the majority of the child’s treatment took place.

CDRMs require planning and co-ordination. Organisations should ensure that those responsible for reviewing child deaths have the proper resources to ensure that meetings are held in a timely and coordinated fashion.

The meeting should take place once investigations have concluded, and reports from agencies and professionals unable to attend the meeting have been received.

The meeting should take place as soon as is practically possible, ideally within three months, although serious incident investigations and the length of time it takes to receive the final post-mortem report will often cause delay.

In order to best capture the views of those directly involved, it may be beneficial to start the process as soon as possible, prior to the formal CDRM

The CDRM should occur before any coroner’s inquest, and before the CDOP meets.


The CDRM may proceed in the context of a criminal investigation, or prosecution, in consultation with the senior investigating police officer. The 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.


4.5 Family engagement

The CDRM is a meeting for professionals. In order to allow full candour among those attending, and so that any difficult issues relating to the care of the child can be discussed without fear of misunderstanding, parents should not attend this meeting. However, parents should be informed of the meeting by their key worker and have an opportunity to contribute information and questions through their key worker or another professional.

At the meeting’s conclusion, there should be a clear description of what follow-up meetings have already occurred with the parents, and who is responsible for reporting the meeting’s conclusions to the family. This would generally be the child’s paediatrician, or in the case of a neonatal death, obstetrician and neonatologist. In a coroner’s investigation, such liaison should take place in conjunction with the coroner’s officers.






Child Death overview Panel


5.1 Introduction

Bucks CDOP review the deaths of all children normally resident within the relevant local authority area. The Panel meets every two months and has representation from health (primary and secondary care), the clinical commissioning group, police, education, social care, the local safeguarding team and public health.


CDOPs should conduct an anonymised secondary review of each death where the identifying details of the child and treating professionals are redacted. This review should be informed by a standardised output, the draft Analysis Form, from the CDRM.

5.2 Panel Responsibilities

The functions of CDOP include:

  • collation of information about each child death
  • analysis of this information to
    • confirm or clarify the cause of death
    • determine any contributory factors
    • identify learning arising that may prevent future child deaths
  • to make recommendations to all relevant organisations which may prevent future child deaths
  • to notify the local Safeguarding Partners in cases involving abuse or neglect
  • to provide data to the National Child Mortality Database;
  • to produce an annual report for CDR partners outlining
    • patterns and trends in child deaths
    • lessons learnt and actions taken
    • effectiveness of the wider child death review process; and
  • to contribute to local, regional and national initiatives to improve child death reviews



Family Engagement and Bereavement Support

6.1 Introduction

Families have the right to have their child’s death reviewed in an attempt to

  • identify the cause of death
  • learn lessons to prevent further children’s deaths


Parents and carers should be informed about and involved in the review process


Appendix II includes contact details for national organisations offering bereavement support.


Professionals in all agencies have a  duty to support bereaved parents. When there are issues of quality of care healthcare organisations have a “duty of candour” to explain what has happened, to apologise as appropriate, and to identify lessons to reduce the likelihood of a repeat incident.


Whether the child’s death is sudden or follows a long illness, the requirement for the following roles is universal:

  • A key worker
  • A medical lead


6.2 The team around the family

The ‘key worker’

All bereaved families should be given a single, named point of contact to whom they can turn for information on the child death review process, and who can signpost them to sources of support

It is the responsibility of the organisation where the child was certified dead to identify a key worker for the family.

The role could be taken by a range of practitioners. For example:

Circumstances of Child Death

Possible key worker

Sudden Unexpected Death

Paediatric Matron Or Member of bereavement support team



Expected Death in child with life limiting illness

Team Leader of Children’s Community nursing team or hospice team

Child with long term condition e.g. e.g. oncology patient

Clinical nurse specialist

Death of baby in Neonatal Unit

Matron for NNU / Bereavement Lead for NNU

Child who dies in community, not known to hospital team e.g. suicide

Coroner’s officer, family liaison officer (police)


Regardless of professional background this person should:

  • be readily accessible point of contact for the family after the death;
  • help co-ordinate meetings between the family and professionals as required;
  • be able to provide information on the child death review process and the course of any investigations pertaining to the child;
  • liaise as required with the coroner’s officer and police family liaison officer;
  • represent the ‘voice’ of the parents at professional meetings, ensure that their questions are effectively addressed, and to provide feedback to the family afterwards; and
  • signpost to expert bereavement support if required.


The ‘medical lead’

An appropriate consultant neonatologist or paediatrician should also be identified after every child’s death to support the family.


This is distinct from the key worker and might either be the doctor that the family had most involvement with while the child was alive or the designated professional on-duty at the time of death. This individual should liaise closely with the family’s key worker and arrange:

  • follow-up meetings at locations and times convenient to the family; and
  • clinical expertise (via other professionals if necessary) to be able to i) answer questions relating to the medical, nursing or midwifery care of the child; ii) explain the findings, where relevant, of the post-mortem examination and /or other investigations and iii) report back the outcome from the CDRM.


Other professionals

At the time of a child’s death, other professionals may also provide vital support to the family; these include (but are not limited to) the GP, clinical psychologist, social worker, school, family support worker, midwife, health visitor or school nurse, palliative care team, chaplaincy and pastoral support team.

In all cases, it is the duty of the key worker to ensure that there is clarity regarding each professional’s role; that the family does not receive mixed messages; and that communication is clear.


6.3 What should bereaved families expect when their child has died?

It should be remembered that bereaved parents may be in state of extreme shock when their child has died. They may not be able to process or retain information and it is common that information needs to be repeated over time. The leaflet When a Child Dies – A Guide for Parents and Carers should be given to all bereaved families or carers.

Providers should be familiar with its contents in order to ensure that bereaved families and carers receive the best support possible. Staff involved with the care of a child should also be offered appropriate support.

When their child dies, bereaved parents or carers should:

  • have the opportunity to spend time with the child’s body in a quiet and private environment;
  • have the opportunity to make memories including taking photographs, hand and foot prints and a lock of hair;
  • expect a member of staff to remain with them, to provide comfort, and to ensure their basic needs are met. In cases where there are suspicious circumstances it will be necessary to have a staff member with the body of the child when the parents are present.
  • be given the contact details of their key worker and the identity of their medical lead, be informed who will be contacting them and when they will be contacted after they leave the hospital or hospice (and what to do should they have any questions in the meantime);
  • know how to make arrangements to view their child’s body;
  • be given information on death registration and the coronial process (if applicable);
  • understand why a post-mortem examination may be indicated and, if so, where it is taking place, and when the results might be expected. In the event of a coroner’s case this responsibility falls to the coroner’s officer;
  • be supported to have an understanding of the child death review process and how they are able to contribute to it;
  • be given practical advice in respect to organising the child’s funeral;
  • have the key worker accompany them to meetings to provide practical and emotional support;
  • be able to access expert bereavement support if required (see below).

6.4 Planning prior to death with life-limiting conditions

Children with life-limiting conditions sometimes die following prolonged illnesses. In these situations, “parallel planning” means planning for the end of life care, even while active treatment is still being pursued. It often involves a palliative care team. It may involve:

  • identifying a ‘team around the family’
  • writing an advance care plan
  • giving thought to cultural and religious requirements


For detailed guidance relating to the planning and management of end of life care in children with life-limiting conditions see:

6.5 When a child dies in the emergency department

  • When children die or are certified dead in the emergency department there will usually be a Joint Agency Response (see section 3.3 for more information). In such circumstances, the same expectations apply relating to identifying a ‘team around the family’.
  • Responsibility for ensuring that appropriate care is provided to the family falls to the organisation in which the child is certified dead. Detailed guidance relating to support for the family in such situations is provided in the SUDI/C Guidelines.

6.6 When a child dies and an Serious Incident Investigation is instigated

  • Where concerns about service delivery have been raised a serious incident investigation may be required. Parents can provide vital insight into the circumstances of the death and quality of care received.
  • In such cases, a “case manager” will support the key worker in having oversight of the various processes, tracking timelines, and ensuring commitments to the family are met.


6.7 Support for parents, families, and carers

Appendix II includes contact details for national charities who offer bereavement support for families. Local NHS services and CDOPs may also offer specific bereavement services. The key worker should be able direct families to the most appropriate support services.




Appendix I - Immediate Decision Making Proforma

Immediate Decision Making Proforma

Name                                      DOB



(Or affix label)                                                                 







Actions to be completed within 1-2 hours of death being declared



Circle as appropriate


Action complete?


Does death meet criteria for a Joint Agency Response?

(death due to external causes, or sudden with no apparent cause, or in custody, or suspicious circumstances, or stillbirth with no healthcare professional in attendance)

If uncertain please discuss urgently with SUDC paediatrician

Yes   /   No

If Yes, contact on-call paediatrician, police, duty social worker and request they attend hospital




Can a MCCD be issued?


Yes   /   No

If No, or if death meets criteria for referral to coroner contact the coroner’s office



Has a Datix form been completed? (Should be completed for all unexpected deaths, and deaths where there are concerns about care or service delivery)






Are there any immediate actions necessary to ensure the health and safety of others, including family or community members, healthcare patients and staff?

Yes / No / NA


If yes, describe here …..


Who has been identified as a key worker?



Who is the medical lead for this child?



Completed on ___/___/____ by         Signed   _____________    Print_____________ Designation__________





Appendix II – Sources of Family Support

The Child Bereavement Trust - http://www.childbereavement.org.uk/

Training, information and support for professionals working with bereaved parents and children, especially babies.

Telephone - 01494 568900

Information and support line – 0800 02 888 40

The Lullaby Trust (Formerly FSID) - https://www.lullabytrust.org.uk/bereavement-support/

A help-line offering support and information to anyone who has suffered the sudden death of an infant.

Help-line: Free phone 0808 8026868

The help-line is also available for family and friends and those professionals involved with the death. The foundation has a wide range of leaflets and information for bereaved families and professionals. It also has a network of befrienders, who are bereaved parents. Arrangements can be made for a befriender to contact the bereaved family to offer additional support.


Child Death Helpline


A helpline for anyone affected by the death of a child, of any age, under any circumstances, however long ago. Helpline is staffed by parents who have experienced the loss of a child in the past.

Helpline available 7-10 pm every evening and 10am –1pm, Monday - Friday.

Telephone 0800 282986 (Free phone) or 0808 800 6019 (mobiles)

Winston’s Wish


Winston’s Wish Family Line offers support, information and guidance to all those caring for a child or young person who has been bereaved.

Family Line 0845 20 30 40 5 (available Mon – Fri 9.30 am – 4.30 pm)

CRUSE Bereavement Care


Helpline available 09.30-17.30 (19.00 Mon and Wed)

  • Amersham - 01494 766 455
  • Aylesbury - 01296 425 757

·       High Wycombe - 01494 511 117

Bereaved Parent Support, Care for the Family

Peer support for bereaved parents including a telephone befriending service


How can you help bereaved parents? BPS Handout resource

Telephone 029 2081 0800



Information and support for families of babies born premature or sick

www.bliss.org.uk   hello@bliss.org.uk 

0808 801 0322

The Compassionate Friends

Peer support for bereaved parents and their families.


0845 123 2304



Appendix III – Sudden Unexpected Death Children and Infants


Medical Record of events of the Sudden Unexpected Death of an Infant or Child


This protocol is to be followed in any case of sudden death in any infant or child

  • Complete all paragraphs
  • Annotate as necessary


This patient record must accompany child’s body to the Mortuary

A copy of this record should be taken to facilitate discussions while notes are unavailable.






DOB                             AFFIX PATIENT LABEL           


Unit Number






































ECG Interpretation





Defibrillation used












Ventilatory Support

Bag & Mask      □                      Intubation □










Resuscitation Drugs




Time(s) Given





















Resuscitation in Hospital


Time Commenced                                       Time Ceased                                                 Decision to stop made by


Those Present         










































History taken by:                                                         


Completed on            ___/____/_____

Signed                         __________________________                   

Print                            __________________________






Unit Number




Vascular Access

Please document all attempted vascular access (Venous, Arterial and Intraosseus)





































Family History

·        Details of all family and household members including names; dates of birth; health - any previous or current illnesses;

·        mental health; any medications; occupation

·        Maternal parity and obstetric history

·        Parental relationships, consanguinity

·        Children, including children by previous partners

·        Household composition

·        Any previous childhood deaths in the family including SIDS

















Past Medical History

·        Of the child, to include pregnancy and delivery; perinatal history; feeding; growth and development

·        Health and any previous or current illnesses; hospital admissions; any medication

·        Routine checks and immunisations

·        Systems review

·       Behavioural and educational history where appropriate


















































Discuss the purpose of the investigations with the parents and confirm their consent in using a hospital consent form.


Results to be sent to the Paediatric Consultant on call’s secretary (NOT to A&E)


Consultants name …………………………..…………………………..


Please order a copy of all results to go to the Paediatric Pathologist in Oxford


If possible obtain the following investigations.







EDTA 1ml + Fluoride Oxalate 1ml

Clinical Chemistry


Identification of poisoning (intentional and non-intentional). MUST be clearly labelled.


Blood Culture


Culture & Sensitivity

Identification of infection – essential to collect as soon as possible as delays may make interpretation difficult


Blood from syringe onto Guthrie card

Clinical Chemistry

Acyl carnitine

Specific investigations for metabolic disorders. Important for all infant deaths.


Blood (Lithium

heparin) 1–2 ml


Normal – keep unseparated

Chromosomes (if dysmorphic features and unknown diagnosis)


LiHep 1.5ml + Fluoride 1ml

Clinical Chemistry

Plasma amino acids, Acylcarnitine, Ammonia, glucose, lactate,

β Hydroxybutyrate,

Free fatty acids

First line investigation to identify possible metabolic disorders


LiHep (0.5ml)

Clinical Chemistry


Can assist in assessing hydration status, severity of illness, renal disorders, metabolic disorders, poisoning (esp. salt poisoning)


EDTA (0.5ml)



Indicator of infection, anaemia, marker of chronic disease, specific or long term illness


CSF2 (5-8 drops)



Microscopy, Culture & Sensitivity

Identification of infection – essential to collect as soon as possible as delays may make interpretation difficult.


CSF2 (5 drops)

Clinical Chemistry


Specific investigations for metabolic disorders.


Swabs from Throat, skin lesions, NPA

Microbiology / Virology

Culture and sensitivity

Swabs from throat and from any skin lesions to identify infections



(if available)

Clinical Chemistry


Organic Acids

Identification of poisons

Organic acids profile indicating metabolic disorders



(if available)


Culture and sensitivity

Identification of urinary tract infection. If bladder is empty do not carry out repeated Suprapubic aspiration.



1)         It is particularly important that this sample is taken and labelled very clearly, and attention is given to the potential importance of the

“continuity of evidence”, e.g. signing for the samples on taking sample and on delivery to the laboratory with a note of times.

2)         ** CSF samples should not be taken if there is a suspicion of cranial trauma.

3)         Blood samples should be taken from a venous or arterial site (e.g. femoral vein) – cardiac puncture should be avoided as this may cause damage to the intrathoracic structures and make post mortem findings difficult to interpret.









Consent to Hospital Post Mortem


Consultants are primarily responsible in negotiating consent for a hospital post mortem unless a post mortem is a legal necessity required by the Coroner. Written and verbal consent will need to be obtained by a consultant from the parents who must be given adequate time to understand their options and the consequences. The consent forms are stored in the Bereavement Office.











Appendix IV - Recommended Investigations


The following table gives a full list of recommended investigations for the investigation of Sudden Death in the Under 2’s as per the guidance produced by The Royal College of Pathologists and the Royal College of Paediatrics and Child Health (2004).


In older children some or all of these investigations can be performed, as dictated by clinical circumstances.



Send to



EDTA 1ml + Fluoride Oxalate 1ml

Clinical Chemistry


Identification of poisoning (intentional and non-intentional). MUST be clearly labelled.

Blood Culture


Culture & Sensitivity

Identification of infection – essential to collect as soon as possible as delays may make interpretation difficult

Blood from syringe onto Guthrie card

Clinical Chemistry

Acyl carnitine

Specific investigations for metabolic disorders

Blood (Lithium

heparin) 1–2 ml


Normal – keep unseparated

Chromosomes(if dysmorphic)

LiHep 1.5ml + Fluoride 1ml

Clinical Chemistry

Plasma amino acids, Acylcarnitines, Ammonia, glucose, lactate,

β Hydroxybutyrate,

Free fatty acids

First line investigation to identify possible metabolic disorders

LiHep (0.5ml)

Clinical Chemistry


Can assist in assessing hydration status, severity of illness, renal disorders, metabolic disorders, poisoning (esp. salt poisoning)

EDTA (0.5ml)



Indicator of infection, anaemia, marker of chronic disease, specific or long term illness

CSF (5-8 drops).

Do not take if suspicion of cranial trauma


Microscopy, Culture & Sensitivity

Identification of infection – essential to collect as soon as possible as delays may make interpretation difficult. Not to be taken if

CSF (5 drops)

Clinical Chemistry


Specific investigations for metabolic disorders.

Swabs from Throat, skin lesions, NPA

Microbiology / Virology

Culture and sensitivity

Swabs from throat and from any skin lesions to identify infections


(if available)

Clinical Chemistry


Organic Acids

Identification of poisons

Organic acids profile indicating metabolic disorders


(if available)


Culture and sensitivity

Identification of urinary tract infection. If bladder is empty do not carry out repeated Suprapubic aspiration.


* It is particularly important that this sample is taken and labelled very clearly, and attention is given to the potential importance of the

“continuity of evidence”, e.g. signing for the samples on taking sample and on delivery to the laboratory with a note of times.


** CSF samples should not be taken if there is a suspicion of cranial trauma.


Blood samples should be taken from a venous or arterial site (e.g. femoral vein) – cardiac puncture should be avoided as this may cause damage to the intrathoracic structures and make post mortem findings difficult to interpret.





Appendix V - Child Death Checklist

Checklist following Death of Child or Young Person (live birth – 17 years inclusive)


To be secured to the front of case notes



Print Name and


Date and


Death verified by doctor and recorded in child’s notes





Mother informed of death





Father informed of death





On-call Paediatric Consultant informed of death





On-call A&E/EMC Consultant informed of death (if child in ED/EMC).




Child’s Consultant (if different to above) informed of death




GP informed of death





Health Visitor informed





Community Midwife informed (if < 28 days)





Bereavement Midwife informed (< 10 days)





Health Visitor informed of death (children <5 years)




Hospice/respite care service informed of death - if relevant?




Neonatal/Children’s Community Nurse informed if involved in care




Mortician informed




Social Worker informed of death if child known to Social Services




Child Death Notification (previously Form A) completed online and sent to Child Death Overview Panel (CDOP) administrator.




Death entered onto appropriate IT system -





Parents given the opportunity to see and hold child




Mementoes given to parents:

Photo/handprint/footprint/lock of hair




Lactation advice given to parent (if still breastfed)





Has spiritual help been requested by the family?


Request forwarded to: Time of request:




Information on tissue/organ donation explained and given to parents if appropriate (refer to section 18 of Bereavement Policy relating to Death of a Neonate, Infant or Child).




Do parents wish to pursue the possibility of tissue/organ donation?




Tissue/organ donation team contacted





Notification of Death Form completed and taken with notes to:




Patient identity bands checked and attached to one wrist and one ankle.




Parent offered opportunity to accompany to Chapel of Rest.




Parent offered opportunity to participate in choice of clothing for last offices as available and appropriate




Parent offered opportunity to select mode of transport to mortuary where possible and appropriate, e.g. carry or transfer in pram/cot/bed/ concealment trolley.




Parent offered opportunity for toy to accompany and remain with child in mortuary




If child’s toy is sent with child this is labelled and recorded on Notification of Death Form




Persons accompanying baby/child to mortuary





Property and clothing handed over to parents/relatives or police in sealed bag?





Bereavement Office informed.





Parent  given  leaflet  and  advised  how  to  contact

Bereavement Office




Property book completed





Debrief to be organised by:






Designated Paediatrician informed of death





Coroner informed of death by contacting the relevant Coroner’s Officers - Weekends or bank holidays for unexpected death call the Thames Valley Police on 101




Specimens   as   agreed   by   Coroner   obtained  

(see Appendix D)





All relevant medical documentation (e.g. casualty card, associated emergency documentation, etc) photocopied and retained by senior attending doctor






Appendix VI - Joint Agency Response - Agenda



1)    Introductions

Introductions and Reason for Meeting, to include an introduction into the Child Death Review process and confidentiality statement.

A contact list should be made with names, titles and contact details of all attendees. (preferably email and telephone)

2)    Immediate Circumstances of the Child’s Death

Each agency / professional involved with the immediate management of the child’s death should give an account of the time surrounding the death. This will include the account from the parents gathered by the paediatric staff, the management in hospital. But may also include:

·       Ambulance Service

·       A&E Staff

·       Children’s Social Care

·       Police

3)    Background Information

Each agency should give an account of their prior involvement with the child and family. Gather information on the following.

·       Family Structure/ Household Composition

·       Child Health

·       Children’s Services inc schools

·       Police

·       Other, including Adult Health

4)    Actions Taken So Far

Gather information from each agency regarding actions completed thus far.

•       Investigations on admission / after death was declared

•       Account of home visit, if this has happened

•       preliminary post mortem results, if available.

•       Has a Key worker been allocated?

5)    Analysis

·       Information missing

·       Siblings’ needs

·       Parents/carers’ needs

·       Control of information and potential media interest

·       Initial view of cause of death and factors related to the death

6)    Conclusions

·       Is the cause of death known? If yes what are the contributory factors to this death that you have identified?

·       What further information is required? 

7)    Action Needed:

·       Home visit, if not already undertaken – who is to attend?

·       Has the death been reported via the DATIX incident reporting system?

·       Does the child’s death meet the criteria for a Serious Incident?

·       Is the death felt to be suspicious?

·       Does the death require a Safeguarding Partnership Review (formerly serious case review)?

·       Has any new information emerged that would suggest abuse or neglect is suspected? If so, joint investigation led by Police and Social Care. Strategy meeting required. (NB: this needs to be an ongoing consideration).

·       Who will follow up on any identified gaps in the information?


This page is correct as printed on Friday 12th of July 2024 10:42:48 PM please refer back to this website (http://bscb.procedures.org.uk) for updates.