Child Death Reviews

When a child dies, in any circumstances, it is important for parents and families to understand what has happened. Families experiencing such a tragedy should be met with empathy and compassion. They need clear and sensitive communication. They also need to understand what happened to their child and know that people will learn from what happened. The process of expertly reviewing all children's deaths is grounded in deep respect for the rights of children and their families, with the intention of preventing future child deaths.

The Child Death Review: Statutory and Operational Guidance (England) says that a child death review should be carried out for all children under 18 years of age regardless of the cause of death. This includes the death of any live-born baby where a death certificate has been issued. In the event that the birth is not attended by a healthcare professional, child death review partners may carry out initial enquiries to determine whether or not the baby was born alive. If these enquiries determine that the baby was born alive the death must be reviewed.

For the avoidance of doubt, it does not include stillbirths, late foetal loss, or terminations of pregnancy (of any gestation) carried out within the law.

• Stillbirth: baby born without signs of life after 24 weeks gestation;
• Late foetal loss: where a pregnancy ends without signs of life before 24 weeks gestation.

Cases where there is a live birth after a planned termination of pregnancy carried out within the law are not subject to a child death review.

The responsibility for ensuring child death reviews are carried out is held by 'child death review partners,' who, in relation to a local authority area in England, are defined as the local authority for that area and any Integrated Care Boards (ICBs) operating in the local authority area.

Child death review partners must make arrangements to review all deaths of children normally resident in the local area.  They may also choose to review the death of a child, including a looked after child, that occurred in their local area even if the child in question was not normally resident there. In such circumstances, the designated doctor for child death in each area should discuss and agree who will be responsible for collecting information and reviewing the death, to ensure there is no duplication of review. The review process should seek to involve child death review partners for another local authority area who had an interest in the child or any other person or agencies.

Child death review partners for two or more local authority areas may combine and agree that their areas be treated as a single area for the purpose of undertaking child death reviews.

Child death review partners must make arrangements for the analysis of information from all deaths reviewed. They should ensure that a designated doctor for child deaths is appointed to any multi-agency panel (or structure in place to review deaths). The designated doctor for child deaths should be a senior paediatrician who can take a lead role in the review process. Child death review partners should ensure a process is in place whereby the designated doctor for child deaths is notified of each child death and is sent relevant information.

The child death review partners should consider the core representation of any panel or structure they set up to conduct reviews and this would ideally include: public health; the designated doctor for child deaths for the local area; social services; police; the designated doctor or nurse for safeguarding; primary care (GP or health visitor); nursing and/or midwifery; lay representation; and other professionals that child death review partners consider should be involved. It is for child death review partners to determine what representation they have in any structure reviewing child deaths.

The purpose of a review and/or analysis is to identify any matters relating to the death, or deaths, that are relevant to the welfare of children in the area or to public health and safety, and to consider whether action should be taken in relation to any matters identified. If child death review partners find action should be taken by a person or organisation, they must inform them. In addition, child death review partners:

• Must, at such times as they consider appropriate, prepare and publish reports on:
• What they have done as a result of the child death review arrangements in their area; and
• How effective the arrangements have been in practice.
• May request information from a person or organisation for the purposes of enabling or assisting the review and/or analysis process - the person or organisation must comply with the request, and if they do not, the child death review partners may take legal action to seek enforcement;
• May make payments directly towards expenditure incurred in connection with arrangements made for child death reviews or analysis of information about deaths reviewed, or by contributing to a fund out of which payments may be made; and may provide staff, goods, services, accommodation or other resources to any person for purposes connected with the child death review or analysis process.

Whilst Child Death Review partners are free to establish their own structure and process to review the deaths of children normally resident in their geographical area of responsibility based on local need, they should ensure that the processes align to the general principles set out in the national guidance in order to enable local lessons to be reflected on at a national level. In the Child Death Review: Statutory and Operational Guidance (England), the body conducting the Child Death Review reviews is identified as a Child Death Overview Panel.

The Child Death Review partners should publicise information on the arrangements for child death reviews in their area. This should include who the accountable officials are (the local authority chief executive and the accountable officer of the Integrated Care Boards (ICBs), which local authority Integrated Care Boards (ICBs) partners are involved, what geographical area is covered and who the designated doctor for child deaths is.

The collation and sharing of the learning from reviews will be managed by the National Child Mortality Database through the use of standardised forms.

Sets out the detailed process to follow including the following areas:

Immediate decision making and notifications - This relates to the immediate actions to be taken after the death of a child, such as notification of death, or deciding whether other investigations are warranted. This includes determining whether the death meets the criteria for a Joint Agency Response.

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 (incl. SUDI/C);
• Occurs in custody, or where the child was detained under the Mental Health Act;
• Where the initial circumstances raise any suspicions that the death may not have been natural; or
• In the case of a stillbirth where no healthcare professional was in attendance.

In practice, the majority of such discussions will happen in a clinical setting, but may require input from other agencies in certain cases.

If the results of any investigations suggest evidence of abuse or neglect as a possible cause of death, whether at home or in the community, all practitioners should inform relevant safeguarding partners and the Child Safeguarding Practice Review Panel immediately.

Criteria for referral of deaths to coroner - covers the reasons for referral to the coroner.

Investigating and information gathering - This is predominantly for those involved in the preliminary stages of the child death review process in the aftermath of a child's death. It also summarises other investigations that may run in parallel to the child death review process.

The Child Death Review Meeting - This relates to the discussion of the death of a child by the professionals who were directly involved in the care of that child during their life and those professionals who were involved in the investigation into their death. The outputs of this meeting will inform the Child Death Overview Panel (CDOP) or equivalent.

Review of child deaths at a Child Death Overview Panel (CDOP) - This describes some of the statutory requirements placed upon child death review (CDR) partners, and the functions that they are expected to carry out. It outlines the function of the Child Death Overview Panel (CDOP)  that should be established to scrutinise all aspects of a child's death, using evidence generated in the steps which precede this stage of the overall child death review process. This is known as a Child Death Overview Panel (CDOP) or equivalent.

Roles and responsibilities of CDOP members - sets out the roles and responsibilities of the different agencies on the panel.

Specific situations - additional guidance covering the areas set out below

Deaths overseas of children normally resident in England

Children with learning disabilities

Deaths of children in adult healthcare settings

Suicide and self-harm

Inpatient Mental Health settings

Deaths in custody

Suggested membership for themed panels - Examples which areas may wish to consider for themed CDOP panels.

Family Engagement and Bereavement Support - Supporting and engaging the family who have lost a child is of prime importance throughout the entire child death review process. Recognising 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.

The key worker for bereaved families responsibilities and competencies - all bereaved families should be given a single, named point of contact, who can provide information on the child death review process, and who can signpost them to sources of support.

Child Death Review Terminology - sets out the definitions used in the guidance.

The death of a child is a devastating loss that profoundly affects bereaved parents as well as siblings, grandparents, extended family, friends and professionals who were involved in caring for the child in any capacity. The Child Death Review process aims to balance improving the experience of bereaved families, and professionals involved in caring for children at a traumatic time with ensuring that information is systematically captured in every case to enable learning from those events to prevent future deaths.

Registrars of Births and Deaths (Section 31 of the Children and Young Persons Act 2008): Requirement on registrars of births and deaths to supply child death review partners with the particulars of the death entered in the register in relation to any person who was or may have been under the age of 18 at the time of death. A similar requirement exists where the registrar corrects an entry in the register.

The registrar must also notify child death review partners if they issue a Certificate of No Liability to Register (where a death is not required by law to be registered in England or Wales) where it appears that the deceased was or may have been under the age of 18 at the time of death.

The information must be provided to the appropriate child death review partners (which cover the sub-district in which the register is kept) no later than seven days from the date the death was registered, the date the correction was made or the date the certificate was issued.

Coroners and Justice Act 2009 & Coroners (Investigations) Regulations 2013: Duty to investigate and hold an inquest. Powers to request a post-mortem and for evidence to be given or produced.

Coroner’s duty to notify the child death review partners for the area in which the child died or where the child’s body was found within three working days of deciding to investigate a death or commission a post-mortem.

Coroner’s duty to share information, including post-mortem reports with the relevant child death review partners.

'When a child dies: a guide for parents and carers' (NHS England) - sets out the steps that follow the death of a child.

See also: Family Engagement and Bereavement Support.

National Bereavement charities that offer helplines, e-mail support, and online communities and message boards for families when a baby or child has died include:

• Child Bereavement UK;
• Hope Again;
• Winston's Wish;
• A Child of Mine;
• At A Loss.org;
• The Good Grief Trust.

See also: Child Death Review Statutory and Operational Guidance (England), Appendix 7: Bereavement resources - organisations which offer bereavement support for families services.

Local areas may well have services that can offer bereavement support more locally.

Child Death Review: Statutory and Operational Guidance (England) - Statutory and operational guidance for Integrated Care Boards (ICBs) and local authorities as child death review partners, which sets out the full process that follows the death of a child who is normally resident in England.

Child death reviews - Chapter 6 of Working Together to Safeguard Children

Child Safeguarding Practice Review Panel Guidance for Safeguarding Partners

Child death reviews: forms for reporting child deaths

Sudden unexpected death in infancy and childhood - multi-agency guidelines for care and investigation - Royal College of Pathologists (RCPath)

Child Death Reviews Legislation - Sections 16M-Q of the Children Act 2004

Sudden and Unexpected Deaths in Infancy and Childhood (National Child Mortality Database NCMD) investigates sudden, unexpected and unexplained deaths in both infants and children and young people, and to draw out learning and recommendations for service providers and policymakers

Safeguarding children at risk from sudden unexpected infant death (Child Safeguarding Practice Review Panel) which sets out recommendations and findings for government and local safeguarding partners to better protect infants from sudden unexpected death in infancy (SUDI).