I) Child Death
"The Child Death Review - A Guide for Parents and Carers"
This leaflet is available for parents and carers of any child under 18 who has died. It explains what happens in the Child Death Review and describes stages of the review including the post-mortem examination, professional meetings, inquests, Child Death Overview Panels, Local Safeguarding Children Boards and includes sources of family bereavement support.
To view the guide click on the Related Files at the end of this page.
Overview of Child Death
Child Death Overview Panel
Staffordshire and Stoke-on-Trent LSCB created a Child Death Overview Panel in April 1st 2008, following the statutory requirement for all Local Safeguarding Children Boards (LSCB) to ensure that a review of each death of a child normally resident in the LSCB’s area is undertaken.
Staffordshire and Stoke-on-Trent LSCB's share one panel. The Panel has a fixed core membership drawn from organisations represented on the LSCB and have flexibility to co-opt other relevant professionals to discuss certain types of death as and when appropriate. The Staffordshire and Stoke-on-Trent CDOP has a professional from public health as well as child health.
The panel is chaired by Detective Superintendent Mark Dean, Staffordshire Police.
Core Panel Members:
- Chair - Detective Superintendent Mark Dean, Staffordshire Police
- Deputy Chair - Heather Widdowson, Designated Nurse South Staffordshire
- Co-ordinator - Faith Lindley-Cooke, Staffordshire Police
- Designated Doctor for Unexpected Death - Dr Azhar Manzoor, Queens Hospital, Burton
- Designated Doctor for Unexpected Death - Dr Alex Tabor, Royal Stoke, University Hospital of North Midlands NHS Trust
- Designated Doctor for Unexpected Death - Dr Martin Samuels, Royal Stoke, University Hospital of North Midlands NHS Trust
- Jemma Simpson, Child Death Overview Panel Nurse Practitioner (North Staffs)
- Rebecca Sage, Child Death Overview Panel Nurse Practitioner (South Staffs)
- Carrie Wain - Staffordshire Safeguarding Children Board Manager
- Carole Preston - Stoke-on-Trent Safeguarding Children Board Manager
- Angela Jervis - Head of Safeguarding, Staffordshire and Stoke on Trent Partnership NHS Trust
- Paula Carr - Designated Nurse NHS Staffordshire Commissioning Support Service
- Kim Wooliscroft - Head of Paediatrics, Mid Staffordshire Representative
- Public Heath Consultant
- Andy Proctor - Head of Safeguarding, West Midlands Ambulance Service
The Child Death Overview Panel should be informed of the deaths of all children normally resident in their geographical area. The Designated person to whom the death notification and other data on each death should be sent is the CDOP Co-ordinator. The Co-ordinator also uses sources available, such as professional contacts or the media, to find out about cases when a child who is normally resident in their area dies abroad.
In cases where organisation in more than one LSCB area have known about or have had contact with the child, lead responsibility should sit with the LSCB for the area in which the child was normally resident at the time of death. Other LSCBs or local organisations which have had involvement in the case should cooperate in jointly planning and undertaking the child death review. In the case of a looked after child, the LSCB for the area of the local authority looking after the child should exercise lead responsibility for conducting the child death review, involving other LSCBs with an interest or whose lead agencies have had involvement as appropriate.
Information relating to all children under the age of 18 is collected using the data set agreed with the Department of
Education (Form B - please see Notification data).
Following review, all actions and recommendations will be tracked and reported back on in the CDOP action sheet following each meeting. The work of the Child Death Overview Panel is summarised in an annual report. More information about the child death review process can be found within Working Together to Safeguard Children 2015, Chapter 5 - Child Death Reviews
Notification of Death
All deaths must be notified to the Child Death Overview Panel Co-ordinator in a timely manner.
For Staffordshire and Stoke-on-Trent this is Faith Lindley-Cooke.
Tel: 0300 123 44 55 ext :2724, Email: firstname.lastname@example.org
Designated Doctor for Unexpected Death (DDUD)
Within Staffordshire and Stoke-on-Trent there are 3 Designated Doctor’s for Unexpected Death and 2 Child Death Overview Panel Nurse Practitioners. They have expertise in undertaking enquiries into unexpected deaths in childhood.
|DDUD for South Staffordshire|
Dr Azhar Manzoor,
01283 511 511 ext 4360
07951 924 576
|DDUD for North Staffordshire|
Dr Martin Samuels, Consultant Paediatrician, Academic Department of Paediatrics,
|Dr Alex Tabor, Consultant Paediatrician, Academic Department of Paediatrics,
Royal Stoke, University Hospital of North Staffordshire NHS Trust, 1st Floor Admin Office, Trent Building, Newcastle Road,
Stoke-on-Trent, ST4 6QG
|Child Death Overview Panel Nurse Practitioners|
For South Staffs (Part Time)
|Office Telephone||01283 511511 2354|
For North Staffs
07775 704 899
A summary of the child death processes to be followed when reviewing all child deaths is set out in the flowchart - Process to be followed for ALL child deaths (click on the link to view the document)
The processes for undertaking a rapid response when a child dies unexpectedly are set out in the flowchart - Process for rapid response to the unexpected death of a child (click on the link to view the document)
I02 Child Death Overview Panel forms
PART 10B When a Child Dies, Notification - Joint guidance between Staffordshire and Stoke-on-Trent Safeguarding Children Boards (Adobe)
Form A - Notification of Child Death
Form B - Agency Report Form
Form B2 - Neonatal Death
Form B4 - Sudden Unexpected Death in Infancy
Form B5 - Road Traffic Accident / Collision
Form B6 - Drowning
Form B7 - Fire and Burns
Form B8 - Poisoning
Form B10 - Substance Misuse
Form B11 - Apparent Homicide
Form B12 - Apparent Suicide
Form B13 - Summary of Autopsy Findings
Form C - Analysis Proforma
Form D - Audit Tool for Rapid Response
Preventing Child Death campaigns: Click here to view the latest local campaigns
Coroners Contact Information:
The North Staffordshire and Stoke-on-Trent Coroner is Mr Ian Smith.
H M Coroner for Stoke-on-Trent and North Staffordshire
547 Hartshill Road
Tel: 01782 234777 Fax: 01782 232074 E-mail:email@example.com
Definition of preventable child deaths
For the purpose of producing aggregate national data, this guidance defines preventable child deaths as those in which modifiable factors may have contributed to the death. These factors are defined as those which, by means of nationally or locally achievable interventions, could be modified to reduce the risk of future child deaths.
In reviewing the death of each child, the CDOP should consider modifiable factors, for example in the family and environment, parenting capacity or service provision, and consider what action could be taken locally and what action could be taken at a regional or national level.
Definition of an unexpected death of a child
In this guidance an unexpected death is defined as the death of an infant or child (less than 18 years old) which was not anticipated as a significant possibility for example, 24 hours before the death; or where there was a similarly unexpected collapse or incident leading to or precipitating the events which lead to the death.
The Regulations relating to child death reviews
The Local Safeguarding Children Board (LSCB) functions in relation to child deaths are set out in Regulation 6 of the Local Safeguarding Children Boards Regulations 2006, made under section 14(2) of the Children Act 2004. The LSCB is responsible for:
a) collecting and analysing information about each death with a view to identifying—
- any case giving rise to the need for a review mentioned in regulation 5(1)(e);
- any matters of concern affecting the safety and welfare of children in the area of the authority;
- any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area; and
b) putting in place procedures for ensuring that there is a coordinated response by the authority, their Board partners and other relevant persons to an unexpected death.
Specific responsibilities of relevant bodies in relation to child deaths
Registrars of Births and Deaths (Children and Young Persons Act 2008)
- Requirement to supply the LSCB with information which they have about the death of persons under 18 they have registered or re-registered.
- Notify LSCBs if they issue a Certificate of No Liability to Register where it appears that the deceased was or may have been under the age of 18 at the time of death. Requirement to send the information to the appropriate LSCB (the one which covers the sub-district in which the register is kept) no later than seven days from the date of registration.
Coroners (Coroners Rules 1984 (as a mended by the Corners (Amendment) Rules 2008
- Duty to inquire and may require evidence. Duty to inform the LSCB for the area in which the child died within three working days of the fact of an inquest or post mortem. Powers to share information with LSCBs for the purposes of carrying out their functions, including reviewing child deaths and undertaking SCRs.
Register General (Section 32 of the Children and Young Persons Act 2008)
- Power to share child death information with the Secretary of State, including about children who die abroad.
Medical Examiners (Coroners and Justice Act 2009)
- It is anticipated that from 2014 Medical Examiners will be required to share information with LSCBs about child deaths that are not investigated by a coroner.
Clinical Commissioning Groups (Health and Social Care Act 2012)
- Employ, or have arrangements in place to secure the expertise of, consultant paediatricians who designated responsibilities are to provide advice on: commissioning paediatric services from paediatricians with expertise in undertaking enquiries into unexpected deaths in childhood, and from medical investigative services; and the organisation of such services.
Sources of Family Bereavement
Bereavement Support in Staffordshire and Stoke-on-Trent
Where to get advice and information:
Child Bereavement UK – Rebuilding lives together. Support and Information www.childbereavementuk.org/
If you are the parent of a baby or child who has died, we can provide booked telephone support sessions for you as an individual
or couple with a qualified counsellor. Please call us to find out more.
Telephone: 0800 02 888 40, Email: firstname.lastname@example.org
For details about the direct support Child Bereavement UK can offer.
A Child of Mine – Help for Bereaved Parents www.achildofmine.co.uk
Telephone: 07803 751229 Office hours: Monday - Friday, 9am - 5pm. Out of hours leave a message and your call will be returned as soon as possible.
Donna Louise Hospice –Staffordshire email@example.com
Offers a network of specialist care and support to children and young people who have life limiting or life threatening illnesses, and their families; includes bereavement support 01782 654440.
Bereavement counselling and support 01782 683 155.
The Lullaby Trust (formerly FSID) firstname.lastname@example.org
Offers confidential support to family, friends and carers affected by the sudden and unexpected death of a baby or toddler: Tel: 0808 802 6868.
Calls to the Helpline are free from all landlines and most mobile phone networks. The Helpline is open: Monday – Friday 10am-5pm, Weekends and public holidays 6pm–10pm
(answered by trained befrienders, all with personal experience of bereavement)
The Helpline does not offer a formal counselling service but rather the opportunity to talk freely, for as long as required, with a sympathetic and understanding listener.
They can also offer support through their team of befrienders. Befrienders are themselves bereaved parents, grandparents and other relatives, who offer personal support which can be arranged via the Helpline.
Winston’s Wish www.winstonswish.org.uk
The largest charity provider of support to bereaved children, young people and their families in the UK. 08452 03 04 05
CLIC Sargent www.clicsargent.org.uk Helping children and young people with cancer 0300 330 0803
Child Death Helpline www.childdeathhelpline.org.uk
A freephone service offering support for anyone affected by the death of a child. 0800 282 986
Stillbirth and Neonatal Death organisation supporting anyone affected by the death of a baby. 02074365881
Information, support and counselling for families with babies “born too small, too soon, too sick”. 0500 618 140
CRUSE Bereavement Care www.cruse.org.uk
Helpline 0844 477 9400
Saying Goodbye www.sayinggoodbye.org,
National remembrance services, 0845 293 8027
The majority of sudden unexpected deaths in infancy are natural tragedies, but a minority are a consequence of ignorance, neglect or abuse. Investigations should keep an appropriate balance between medical and forensic requirements and should take account of possible risks to other children in the household.
Professionals should approach with an open mind and families should be treated with sensitivity, discretion and respect.
There should be a multi-agency approach involving collaboration among: emergency department staff, ambulance, staff, child protection co-ordinators, coroners, coroners officers, GP's , health visitors, midwives, paediatricians, pathologists, police and social workers.
Over the years, detailed study of sudden infant deaths has led to the recognition of factors that are of importance in understanding and preventing such tragedies (e.g. the infant's sleeping position, parental smoking, and inappropriate sleeping environments). It is therefore important that this investigative approach is emphasised in all dealings with the bereaved family. The increasing ability to identify metabolic and other medical causes of sudden death in infancy and the mounting (and reasonable) expectation of parents that such conditions should be identified requires a wide and up to date knowledge of the familiarity with the literature in this field, together with considerable experience in the recognition of particular patterns of presentation of different conditions. Sudden unexpected deaths in infancy (SUDI) are now far less common than in the past.
The Staffordshire and Stoke-on-Trent Multi agency Protocol gives guidance for sudden and unexpected deaths and how each
agency should respond.
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