8.4 Rapid Response Procedure

The vast majority of sudden child deaths are the result of natural causes and are a tragedy for any family. Every child who dies deserves to have their sudden and unexplained death fully investigated so that a cause of death can be identified.

This procedure sets a minimum standard for a rapid response service for unexpected deaths in infancy and childhood, as outlined in Working Together to Safeguard Children.

This procedure applies when a child dies unexpectedly (from birth up to the 18^th birthday, excluding stillborn babies), or where there is a lack of clarity about whether a death of a child is unexpected.

It is acknowledged that each death has unique circumstances and professionals involved have their own experience and expertise, which is drawn upon in handling individual cases.

This procedure provides guidance on capturing immediate information about an unexpected child death, while also giving support to the bereaved family. This ensures that early opportunities for information-gathering are not lost.

Throughout this procedure, the term ‘parent’ is used to refer to any parent or carer, including the person with a Special Guardianship Order or Residence Order, foster parents and the local authority for those in care.

An unexpected death is defined as a the death of an infant or child which was not anticipated as a significant possibility, for example 24 hours before the death; or where there was an unexpected collapse or incident leading to, or precipitating, the events which lead to the death.

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

When a child with a known life-limiting and or life-threatening condition dies in a manner or at a time that was not anticipated, the rapid response team should liaise closely and promptly with a member of the medical, palliative or end-of-life care team who knows the child and family, to jointly determine how best to respond to the child’s death.

The ‘Designated Paediatrician’ responsible for child death should be consulted where professionals are uncertain about whether the death was unexpected. If in doubt, the processes for unexpected child deaths should be followed until the available evidence enables a different decision to be made (i.e. until it becomes clear that the death was expected).

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 unexplained child death, all agencies need to follow these common principles:

• ensuring sensitivity
• maintaining an open mind/balanced approach
• maintaining an inter-agency approach
• sharing information
• responding appropriately to the circumstances
• preserving evidence.

The service response to an unexpected child death should be safe, consistent and sensitive to those concerned. Bereaved parents and siblings should receive a similar response across Buckinghamshire.

Professionals should be aware that, in certain circumstances, separate investigative processes may be taking place alongside those described in this procedure (e.g. murder investigations, Sudden Unexpected Death in Infancy [SUDI] processes). Professionals and agencies should liaise across processes to avoid duplication.

The purpose of a rapid response service is to ensure that the appropriate agencies are engaged and work together to:

• Ensure support for the bereaved siblings, family members or members of staff who may be affected by the child’s death. The death of a child will always be a traumatic loss – the more so if the death was unexpected (see Cruse for more information).
• Identify and safeguard any other children in the household or any other children that may be affected by the death.
• Respond quickly to the unexpected death of a child.
• Make immediate enquiries into, and evaluate the reasons for and circumstances of, the death, in agreement with the coroner when required.
• Preserve evidence in case a criminal investigation is required.
• Enquire about, and constructively review, how each organisation discharged their responsibilities when a child dies unexpectedly (liaising with those who have ongoing responsibilities for other family members), and determine whether there are any lessons to be learnt.
• Collate information in a standard format (see Government guidance for details of national templates for Local Safeguarding Children Partnerships (LSCPs) to use when collecting information about child deaths). In Buckinghamshire this can now be done online through eCDOP. Please contact the Child Death Overview Panel (CDOP) Coordinator for a log-in to the system.
• Cooperate appropriately post-death, maintaining contact at regular intervals with family members and other professionals who have ongoing responsibilities to the family, to ensure that they are appropriately informed (unless such sharing of information would place other children at risk of harm or jeopardise police investigations).
• Consider media issues and the need to alert and liaise with the appropriate agencies.
• Maintain public confidence.

Rapid response begins at the point of death and ends when the final meeting has been convened and chaired by the designated paediatrician or equivalent. Any records of the meeting (i.e. statutory child death reporting form, meeting notes) should be forwarded to the CDOP at the time of the review.

The area in which the death of a child has been declared must take initial responsibility for convening and co-ordinating the rapid response process, until agreement for handover can be secured with the area where the child was normally resident.

Where notified of a death abroad, the professionals responsible for child death in the local authority where the child is normally resident must consider implementing this procedure as far as is practically possible, and fully record any decisions made.

The Designated Paediatrician has responsibility for ensuring a rapid response team is formed in response to each unexpected child death and that the rapid response process is carried out by them.

In the absence of the Designated Paediatrician, the on-call senior attending doctor will take on these duties and report progress to the Designated Paediatrician at the earliest opportunity. The Designated Paediatrician therefore maintains senior oversight of all cases requiring a rapid response.

In Buckinghamshire, young people aged 16 to 18 do not normally come under the remit of paediatricians. Where there is an unexpected death in a young person aged between 16 and 18, the Accident and Emergency Consultant or other medical consultant will initiate the rapid response process, whilst consulting the Designated Paediatrician.

The Designated Paediatrician is responsible for ensuring all actions relating to the rapid response process are completed. The rapid response timeline involves three phases:

• Phase one (usually 0–5 days after the death): the management of information sharing from the point at which the child’s death becomes known to any agency until the initial results of the post-mortem have been completed.
• Phase two (usually 5–7 days after the death): the management of information sharing once the initial post-mortem results are available.
• Phase three (usually 8–12 weeks after the death): the management of information sharing through the case discussion meeting when the final post-mortem report is available.

It is important that all agencies are clear that the rapid response process is multi-dimensional, the information flow is variable, and that a number of different processes can occur at the same time, e.g. child protection or criminal enquiries.

Immediate response

• Children who die unexpectedly in the community should be taken to an accident and emergency department (A&E) and resuscitation should always be initiated unless clearly inappropriate. See the Resuscitation Council (UK) Resuscitation Guidelines (2015).²
• Please note that all child deaths in the community should be taken to Stoke Mandeville Hospital. The child should never be taken straight to the mortuary unless directed by the police in consultation with the coroner.
• The police, social care and coroner must be informed as soon as possible. The senior attending doctor will take responsibility for ensuring this happens.
• As with children who die in hospital, their parent/s should be allocated a member of hospital staff to support them throughout the process.
• A child should not be taken to A&E in situations where:
  • the circumstances of the death require the child’s body to remain at the scene for forensic examination (police will be involved in these cases and decisions will be made after consideration by the Senior Investigating Officer)
  • the death was expected in the context of the child’s life-limiting condition and they were receiving palliative care
  • the child had a ‘do not resuscitate’ agreement, as confirmed in the care plan.³

• Where a child is not taken immediately to A&E, the professionals confirming the death should inform the coroner, the Designated Doctor for Child Death Reviews and the Designated Paediatrician at the earliest opportunity. This death will be subject to local coronial guidelines if the doctor is unable to issue a medical certificate of the cause of death.
• The families of children who are not taken to hospital should receive support throughout the process from a professional whose role is to provide such support.

On arrival at hospital

• It is important to respond quickly to the unexpected death of a child. As soon as practicable (i.e. as a response to an emergency) after arrival at a hospital, the child should be examined by the consultant paediatrician or delegated senior paediatric clinician on call. In some cases, this examination might be undertaken jointly with a consultant in emergency medicine or, for some children over 16 years of age, the consultant in emergency medicine may be more appropriate than a paediatrician.
• A detailed and careful history of events leading up to and following the discovery of the child’s collapse should be taken from the parents/carers. Best practice is to take a history from the parents/carers separately, although it is recognised that this may sometimes be impracticable. This recognises that clinical consultations have greatest evidential value if it is possible to establish the pattern of consistency and inconsistency in the accounts of the carers.
• It is important to document all that is said by the family in a precise and non-judgemental fashion. This may be crucial to the evidence required by the coroner and/or any subsequent investigation.
• Where the cause of death, or factors contributing to it, is uncertain, investigative samples should be taken immediately on arrival and after the death is confirmed. In order to be compliant with the Human Tissue Act 2004, the removal of these investigative samples must take place on Human Tissue Authority licensed premises with the authorisation of the coroner (or, where the coroner is not involved, the consent of a parent). The samples need to be agreed in advance with the coroner and should include the standard set (listed in Table 1 of Sudden Unexpected Death in Infancy and Childhood, Royal College of Pathologists and Royal College of Paediatrics and Child Heath, 2016⁴).
• Consideration must be given to undertaking a full skeletal survey and, if this is appropriate, it should be done prior to autopsy. This will be arranged by the Paediatric Pathologist in Oxford.
• In seeking to clarify the cause of death and the factors which contributed to it, the paediatrician should document:
  • a full account of any resuscitation and any interventions of investigations carried out
  • an account by the parent/carer, including narrative, of the events leading to the death
  • a body chart documenting the examination findings and any post-mortem changes.
• When the child is pronounced dead, the medical 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. The medical consultant must seek consent from those with parental responsibility for the child if the tissue is to be retained beyond the period required by the coroner. However, consent will not be required if tissue blocks and slides are required for the purpose of criminal procedures relating to the death.
• The medical consultant who saw the child must inform the Designated Paediatrician immediately after the coroner is informed. The same processes will apply to a child who is admitted to a hospital ward and subsequently dies unexpectedly in hospital.
• The Designated Paediatrician is responsible for co-ordinating the multi-agency response, and must ensure that the following have been notified:
  • coroner
  • police
  • other agencies as appropriate (e.g. local authority Children’s Social Care).
• And, in a timely manner, will notify:
  • CDOP (using Form B – Agency Report)
  • Director of Public Health.

Involvement of the coroner

• Once death has been declared, the coroner assumes immediate responsibility of the child’s body and no further samples for investigations may be taken without the coroner’s permission.
• It is helpful to have agreed in advance a standard set of investigations that can be done on all sudden unexpected deaths so that time is not wasted trying to seek consent for individual cases. Taking specimens in A&E will prevent delays which may affect the value of the specimens (see Sudden Unexpected Death in Infancy and Childhood, Royal College of Pathologists and Royal College of Paediatrics and Child Heath, 2016⁴).
• No items (e.g. clothing) 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 in medical records when handed over to either the police or pathologist, including the date, time and details of who has taken responsibility for such items, i.e. police officer’s identification number, role and place of work.

Multi-agency planning discussion

• The Designated Paediatrician must ensure that information is shared and must initiate a planning discussion between relevant agencies such as the police, health (e.g. ambulance staff, named and designated doctors, liaison health visitor, general practitioner, midwife, pathologist), local authority Children’s Social Care and relevant others, including the coroner’s office, in a timely manner to decide next steps. This may or may not involve a meeting.
• Where an unexpected death occurs in a hospital, the plan should also address the actions required by the NHS Trust’s Serious Unexpected Incidents Protocol (SUI). Where the death occurred in a custodial setting, the plan should ensure appropriate liaison with the investigator from the Prisons and Probation Ombudsman.
• For each unexpected death of a child (including those not seen in A&E), urgent contact should be made with any other agencies who know of, or are involved with, the child (including Child and Adolescent Mental Health Services [CAMHS], school or early years) to inform them of the child’s death and to obtain information on the history of the child, the family and other members of the household. If a young person is under the supervision of Youth Offending Service (YOS), they should also be approached. Refer to the list of lead officers/staff in key agencies.

Immediate support for family

• 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.
• Where parents do not understand and/or speak English well, an independent interpreter should be called. The interpreter should not normally be a family member. However, urgent information about the child could be sought from a family member while waiting for an interpreter to arrive.
• Remember that families are in the first stages of grief. They may be shocked, numb, withdrawn, angry or hysterical.
• The family should be allocated a member of staff to remain with them and support them throughout the process. The family should normally be given the opportunity to hold and spend time with their child in a quiet designated area. The allocated member of staff should maintain a discrete presence throughout.
• Before leaving the hospital or, if the child died at home, before the professionals leave the home, the parents should be given details of the lead professionals (consultant paediatrician, senior investigating police officer or coroner’s office), and the details of who they should contact for information on the progress of any investigation or if they wish to visit the hospital to see their child. Parents should be kept informed of the whereabouts of their child.
• Communication with parents/family at this early stage is critical and should involve the following:
  • Communications should be clear, sensitive and honest.
  • Parents should be treated with compassion, respect and dignity.
  • Every effort should be made to conduct discussions in a private and sympathetic environment away from interruptions.
  • The child should be referred to by name and s/he always handled as if s/he were still alive.
  • It is important to take into account religious and cultural beliefs which may impact upon procedures. In all but exceptional circumstances, i.e. when crucial forensic evidence may be lost or interfered with, this should be allowed, albeit with observation by an appropriate professional.
  • The family should be informed that the death will be notified to the coroner and a post-mortem will be required. They should also be informed of the involvement of the police and social care.
  • Verbal communication may need to be complimented with written material (a useful leaflet is The Child Death Review – a guide for parents to the Child Death Review process)

Multi-agency involvement

• The involvement of the police is routine and does not assume suspicion.
• Where the death is unexplained and there are concerns about abuse or neglect, the police will be the lead agency. It will be the responsibility of all relevant partner agencies to support the police investigation. It is therefore vital that staff maintain accurate records of their involvement with the family so that all relevant information can be obtained effectively and in a timely manner.
• The family may well be in need of support services and any other children within the family may be in need of protection. Inter-agency collaboration is therefore essential. Staff need to be aware that, on occasions, the early arrest of the parent/carer may be essential in order to secure and preserve evidence as part of an investigation.
• Staff should always identify and enquire about the siblings and ensure they are being cared for appropriately, taking account of possible risks to other children in the household.

Police investigation

The police will begin an investigation into the unexpected death of a child on behalf of the coroner. They will carry this out in accordance with College of Policing guidelines.

Potential visit to the place where the child died

• When a child dies unexpectedly in a non-hospital setting, the senior investigating police officer and Designated Paediatrician should make a decision about whether a visit to the place where the child died should be undertaken. For all children aged 2 years and under, the SUDI⁴ protocol must be followed.
• As well as deciding if the visit should take place, it should be decided how soon within the 24 hours it should take place, who should visit and whether there would be an advantage in the professionals visiting separately. This will be a matter for professional judgement and agreement. The professional responsible for the decision is the investigating police officer. The senior attending doctor or equivalent will provide contact details to the police of any health professionals they require to support any visits.
• The purpose of the home visit is to gather information which may provide immediate insight into the cause of death, or which may later prove significant to the coroner or to any criminal investigation, or may prompt a child protection referral. The visit can also provide support to the family as part of their bereavement process.

A case discussion should take place as soon as practicable and, in any case, within one week of the child’s death, in order to:

• ensure the right support is available for the family
• ensure all agencies are aware of their roles and responsibilities
• review the preliminary post-mortem results (if available)
• identify any safeguarding concerns around surviving children, and refer accordingly to the police child protection team and Children’s Social Care
• ensure agencies are collating information for Form B
• ensure all relevant agencies are involved in the process
• identify what further investigations or enquiries are required, agree which agency will undertake each task and agree timescales (which may not exceed those set out in this procedure) – if abuse or neglect appear to be a possible cause of death, Children’s Social Care and the police should be informed and Serious Case Review procedures considered by Buckinghamshire Safeguarding Children Partnership (BSCP).

Prior to this meeting, the Designated Paediatrician should discuss the case with the pathologist (when a post-mortem has taken place and consent obtained from the coroner) and the police senior investigating officer, where appropriate.

Involvement of the coroner and pathologist

• If she/he deems it necessary (and in almost all cases of an unexpected child death it will be), the coroner will order a post-mortem examination to be carried out as soon as possible. The pathologist will perform the examination according to the guidelines and protocols laid down by the Royal College of Pathologists.
• The Designated Paediatrician should collate information collected by those involved in responding to the child’s death and share it with the pathologist.
• Where the death may be unnatural, or the cause of death has not yet been determined, the coroner will in due course hold an inquest.
• All information collected relating to the circumstances of the death, including a review of all relevant medical, social and educational records, must be included in a report for the coroner prepared jointly by the lead professionals in each agency. The report should be delivered to the coroner within 28 days of the death, unless some of the crucial information is not yet available.
• The results of the post-mortem examination belong to the coroner. In most cases it is possible for these to be discussed by the paediatrician and pathologist, together with the senior investigating police officer, as soon as possible, and the coroner should be informed immediately of the initial results.
• If the initial post-mortem findings, or findings from the child’s history, suggest evidence of abuse or neglect as a possible cause of death, the police and Children’s Social Care should be informed immediately, and the BSCP Serious Case Review processes should be followed.
• If there are concerns about surviving children living in the household, professionals should follow the BSCP procedure for What to do if you are concerned about a child in Buckinghamshire.
• If the post-mortem examination reveals no sufficient identifiable cause of death, whether or not any concerns have been raised during the post-mortem examination or previously about the possibility of abuse or neglect, the pathologist should categorise the death as ‘unexplained pending further investigations’ and the coroner should in every case hold an inquest.

A further case discussion meeting should be convened and chaired by the Designated Paediatrician (or other relevant professional where negotiated) following the final results of the post-mortem examination becoming available. This should involve those who knew the child and family, and those involved in investigating the death – the GP, health visitors, school nurse, paediatricians, pathologist (or pathologist report), police senior investigating officers, coroner or coroner’s office, and, where relevant, social workers.

At this stage, the collection of the Child Death Core dataset should be completed: Form D – Audit tool for Rapid Response and Form B13 – Summary of autopsy findings.

The discussion meeting should explicitly address the possibility of abuse or neglect as causes or contributory factors in the death, and the outcomes of this should be recorded.

The meeting should agree how and by whom the parents will be informed about the post-mortem results and the outcome of the meeting. This meeting should also agree how and by whom the parents will be offered ongoing support and given the opportunity to have their views taken into account by the CDOP review.

Where other investigations are ongoing, the meeting should conclude with a record of the current situation.

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 discussion and the record of the core data set should also be made available to the BSCP’s CDOP Panel.

When a child dies away from their normal place of residence, a joint decision will need to be made by the rapid response teams in both areas as to which team will lead the investigation and in which Local Safeguarding Children Partnership (LSCP) area the case review meeting should be held. On occasions, separate meetings may be appropriate in both LSCP areas, but good communication between the teams is essential.

Media issues

• The BSCP will manage all media interest, and will ensure relevant partners are involved.
• Staff must be enabled to proceed with their functions without intrusion and the family provided with privacy.
• Any information released to the media must be agreed by all relevant BSCP agencies via their respective press offices.

Expected child deaths

• When a child’s death is not regarded as ‘unexpected’, the team looking after the child may choose to organise a discussion of the case, since it is likely that important lessons can be learnt that might improve the care of other children. Such a discussion may be conducted using the same format as a professionals’ meeting, the output of which could be captured on the Analysis Proforma (Form C).
• Information from these discussions provides the CDOP with evidence of good local practice and allows for wider engagement of professionals with the child death review process.

Support for staff

• Child deaths will have varying degrees of impact on staff. Agencies need to be aware that clear procedures, effective communication and leadership will provide staff with confidence and enable them to respond appropriately to families. Staff may respond to the emotions involved and agencies should have arrangements in place to manage this.
• Where required, staff should be offered support through a formal debrief system and counselling via relevant welfare support provided by the place of work.