Child Death Review Process


The North Yorkshire Safeguarding Children Board (NYSCB) & City of York Safeguarding Children Board (CYSCB) 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 NYSCB and CYSCB are responsible for:

(a) collecting and analysing information about each death with a view to identifying -

  (i) any case giving rise to the need for a review mentioned in regulation 5(1)(e);

  (ii) any matters of concern affecting the safety and welfare of children in the area of the authority;

  (iii) 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.

This guidance sets out the procedures to be followed when a child dies in City of York and North Yorkshire area and is based on Chapter 5 of Working Together to Safeguard Children (2015). They do not replace existing procedures for the investigation of child protection referrals.


All child deaths must be notified to the LSCB in the area in which the child died. Where the child dies in North Yorkshire or York, then referral must be to the CDOP Coordinator at the address in Appendix 2, regardless of the home address of the child. Where a child resident in North Yorkshire or York dies out of the area, then the LSCB for that area should be notified.

Notification should take place within 24 hours of the death and should be made by the person certifying death or any other professional involved. Coroners' Officers will also notify the CDOP Team for those deaths they are informed of.

Other professionals who become aware of a child death are encouraged to contact the CDOP Coordinator to ensure that deaths have been notified and to provide whatever information they have to support the process.

The Notification of Child Death can be carried out by completing the secure online Form A which can be found on the NYSCB website.  A copy of the Form A can also be sent by secure e-mail to the CDOP Coordinator. All postal communication should be sent by recorded delivery.

The Designated Doctor for Child Deaths should also be notified of each death by the CDOP Coordinator.

The information required at the time of notification includes:

  • Child's name
  • Date of birth
  • Address
  • Next of Kin
  • Consultant Paediatrician involved in the care of the child prior to death
  • Child's GP
  • School if in education
  • Place of death, time and date
  • Brief details regarding nature  of death
  • Referrer’s details

If the death is unexpected, details of the Joint Agency Response Meeting

On receipt of an initial notification of a possible child death, the CDOP Coordinator will attempt to confirm this information by contacting the relevant local agencies who may have been involved.  Each relevant agency will be contacted and given the information on the identity of the child, members of the household together will other relevant contacts or family members.

The use of the child's NHS number as a unique identifier will minimise the risk of mistaken identity or duplication of notifications.

Having ensured that relevant agencies are aware of the child's death, the next stage of the process is to ensure that they are involved in the preparation for any local case review meetings to investigate and review the circumstances of the case, any contributory factors and the on-going support needs of the family, and to contribute to the Child Death Overview Panel's review.

Types of Investigations

There are two interrelated processes for reviewing child deaths (either of which can trigger a Serious Case Review):

A Joint Agency Response by a group of key professionals who came together for the purpose of enquiring into and evaluating each unexpected death of a child.

An overview of all child deaths (under 18 years) in the City or York and North Yorkshire areas, undertaken by the joint City of York and North Yorkshire Child Death Overview Panel (CDOP).


The responsibility for determining the cause of death rests with the Coroner or the doctor who signs the medical certificate of the cause of death (and therefore is not the responsibility of the Child Death Overview Panel (CDOP)).

The table below identifies the responsibilities of relevant bodies/organisations in relation to the Child Death Review Process (CDRP).



Local Safeguarding Children Board

The NYSCB & CYSCB are responsible for ensuring that a review of each death of a child normally resident in North Yorkshire and the City of York is undertaken. The Panel will have a fixed core membership drawn from organisations represented on the NYSCB & CYSCB with flexibility to co-opt other relevant professionals to discuss certain types of death as and when appropriate (for example involving CAMHS during a review where mental health issues have been a factor in a child’s death). The Panel includes a professional from public health as well as child health. It is chaired by the NYSCB Chair's representative.

The NYSCB and CYSCB will use 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. The NYSCB & CYSCB will inform the Child Death Overview Panel (CDOP) of such cases so that the deaths of these children can be reviewed.

In cases where organisations 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.

Responsible for 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.

The NYSCB will supply anonymised data regularly on child deaths to the Department for Education.  This is to enable the Department to commission research and publish nationally comparable analyses of child deaths.

Child Death Overview Panel

The functions of the CDOP include:

  • reviewing all child deaths up to the age of 18, excluding those babies who are stillborn and planned terminations of pregnancy carried out within the law;
  • collecting and collating information on each child and seeking relevant information from professionals and, where appropriate, family members;
  • discussing each child's case, and providing relevant information or any specific actions related to individual families to those professionals who are involved directly with the family so that they, in turn, can convey this information in a sensitive manner to the family;
  • determining those deaths in which modifiable factors may have contributed to the death and decide what, if any, actions could be taken to prevent future such deaths;
  • making recommendations to the LSCB or other relevant bodies promptly so that action can be taken to prevent future such deaths where possible;
  • identifying patterns or trends in local data and reporting these to the LSCB;
  • where a suspicion arises that neglect or abuse may have been a factor in the child's death, referring a case back to the LSCB Chair for consideration of whether an SCR is required;
  • agreeing local procedures for responding to unexpected deaths of children; and
  • cooperating with regional and national initiatives - for example, with the National Clinical Outcome Review Programme - to identify lessons on the prevention of child deaths.
  • identifying patterns or trends in local data and reporting these to the NYSCB and Identify any public health issues and consider, with the Clinical Commissioning Groups, how best to address these; and co-operate with regional and national initiatives – e.g. the Confidential Enquiry into Maternal and Child Health (CEMACH) – to identify lessons on the prevention of unexpected child deaths.
  • Monitor and advise the LSCB on the resources and training required locally to ensure an effective inter-agency response to child deaths;
  • Monitor the response to unexpected child deaths including reports produced by the Joint Agency Response team and, where appropriate, provide professionals with feedback;
  • Pass specific new information to the Coroner or other authorities as appropriate;
  • Organise and monitor the collection of data for the nationally agreed minimum data set, and make recommendations (to be approved by LSCBs) for any additional data to be collected locally

Registrars of Births and Deaths (Children & 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 amended by the Coroners (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

Registrar 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.

Clinical Commissioning Groups (Health and Social Care Act 2012)

Employ, or have arrangements in place to secure the expertise of, consultant paediatricians whose 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.

Designated Paediatrician for unexpected deaths in childhood

(designated paediatrician)

Ensure that relevant professionals (i.e. coroner, police and local authority social care) are informed of the death; coordinate the team of professionals (involved before and/or after the death) which is convened when a child who dies unexpectedly (accessing professionals from specialist agencies as necessary to support the core team).

Convene multi-agency discussions after the initial and final initial post mortem results are available.

To provide advice and guidance when there is doubt in determining whether a death should be considered as expected or unexpected


Ultimately the circumstances of an unexpected death will be examined by HM Coroner, but they may also form the basis of criminal prosecution and other legal proceedings. Any unexpected death of a child is a tragedy for the family members and therefore any enquiries or investigations need to balance forensic and medical requirements with the family's need for support.

A small minority of unexpected deaths are the consequence of abuse or neglect, or these are found as associated factors. In all cases, enquiries should seek to understand the reasons for the child's death, address the possible needs of other children in the household, the needs of all family members, and also consider any lessons to be learnt about how best to safeguard and promote children's welfare in the future.

Families should be treated with sensitivity, discretion, and respect at all times, and professionals involved should approach their enquiries with an open mind.

Definition of unexpected death

An 'unexpected death' is the death of a child ( birth to 18 years, excluding babies still born) which was not anticipated as a significant possibility 24 hours before the death, or where there was a similarly unexpected collapse leading to or precipitating the events that led to the death.

A child who dies with a known disability or medical condition should be responded to in the same manner as any other child.

The designated paediatrician responsible for unexpected deaths in childhood should be consulted where professionals are uncertain about whether the death is unexpected. If in doubt, the processes for unexpected child deaths should be followed until the available evidence enables a different decision to be made.

Responding to an unexpected death

If the child dies suddenly or unexpectedly at home or in the community, the child should normally be taken to an Emergency Department rather than a mortuary. In some cases when a child dies at home or in the community, the police may decide that it is not appropriate to immediately move the child's body, for example because forensic examinations are needed.

As soon as possible after arrival at a hospital, the child should be examined by a consultant paediatrician and a detailed history should be taken from the parents or carers. The purpose of obtaining this information is to understand the cause of death and identify anything suspicious about it. In all cases when a child dies in hospital, or is taken to hospital after dying, the hospital should allocate a member of staff to remain with the parents and support them through the process.

If the child has died at home or in the community, the lead police investigator and senior health care professional should decide whether there should be a visit to the place where the child died, how soon (ideally within 24 hours) and who should attend. This should almost always take place for cases of sudden infant death. See the Munro Review of Child Protection: Final Report: A Child Centred System, Cm 8062, May 2011.

After this visit the senior investigator, visiting health care professional, GP, health visitor or school nurse and local authority children's social care representative should consider whether there is any information to raise concerns that neglect or abuse contributed to the child's death.

Reporting of Child Deaths to other bodies

Where a child dies unexpectedly as well as notifying the NYSCB CDOP Coordinator, all registered providers of healthcare services must notify the Care Quality Commission of the death of a service user – but NHS providers may discharge this duty by notifying the National Health Service Commissioning Board (Regulation 16 of the Care Quality Commission (Registration) Regulations 2009). Where a young person dies at work, the Health and Safety Executive should be informed. Youth Offending Teams' reviews of safeguarding and public protection incidents (including the deaths of children under their supervision) should also feed into the CDOP child death processes.

Eight Key considerations for Child Death

The eight key aspects for consideration when a child death occurs are (Section 14, Table 1):

  • Care of the bereaved family: This includes the welfare and protection of remaining siblings, spiritual needs of the family and where appropriate, involvement of the extended family;
  • Deciding upon the response: Deciding on whether the death is unexpected and whether to implement the Joint Agency Response procedure;
  • Joint Agency Response : Unexpected deaths follow the processes for Joint Agency Response
  • Notification to a CDOP: The Child Death Overview Panel will be notified of all child deaths by the attending Consultant Paediatrician or other professional, using the notification Form A.
  • Child Protection: Emerging information giving rise to child protection concerns about remaining siblings/other children or peer group will require formal notification to Children's Social Care in line with local LSCB procedures;
  • Serious Case Review: All agencies must be mindful of any emerging information giving rise for the LSCB to consider conducting a serious case review. The decision to undertake the review will be taken by the Chair of the LSCB where the child normally resides. Serious Case Reviews will operate simultaneously with the Joint Agency Response procedure;
  • Media issues: There should be a coordinated response to media enquiries, agreed by all relevant agencies (where possible at the case discussions). Where appropriate, media enquiries should be directed to the relevant press office;

Support to staff: There will be varying degrees of impact upon staff and agencies need to have arrangements in place to manage this.

Responding to the unexpected death of a child: Joint Agency Response

Joint Agency Response describes the process of communication, collaborative action, and information sharing following the unexpected death of a child. The purpose of Joint Agency Response is to ensure that the appropriate agencies are engaged and work together to:

  • 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;
  • Undertake the types of enquiries that relate to the current responsibilities of each organisation when a child dies unexpectedly;
  • Collate information in a standard format;

Work together appropriately post death, keeping contact with family members and relevant professionals to ensure that they are appropriately informed.

Joint Agency Response begins at the point of death and ends with the completed report to the Child Death Overview Panel.

The investigation and management of unexpected death in childhood must follow a multi-agency approach, maintaining a balance between medical and forensic requirements whilst taking account of the needs of the family.

All cases of unexpected death in childhood must be referred to the coroner.

Immediate response to the unexpected death of a child in the community

If the first professionals on the scene are not medical professionals, then they must obtain urgent medical assistance as the first priority.

Death should not be assumed and therefore the first immediate response should be:

  • Initiate immediate resuscitation unless clearly inappropriate. Resuscitation once commenced should be continued according to the Resuscitation Council (UK) Guidelines (2015);
  • The child should be transferred to the nearest Accident and Emergency (A&E) Department by ambulance, unless there is instruction not to do so by the police and resuscitation has not been initiated. In such cases the child will be taken to the hospital mortuary.
  • Prior to arrival at A&E, provide relevant information and history to the A&E staff;
  • Notify the Police if they are not already present.

When a child dies suddenly and unexpectedly, the consultant clinician (in a hospital setting) or the professional confirming the fact of death (if the child is not taken immediately to an Accident and Emergency Department) should inform the Local Designated Paediatrician with responsibility for unexpected child deaths at the same time as informing the Coroner and police. The police will begin an investigation into the sudden or unexpected death on behalf of the coroner. The Consultant Paediatrician should initiate an immediate information sharing and planning discussion between the lead agencies (i.e. health, police and local authority children's social care) to decide what should happen next and who will do it. The joint responsibilities of the professionals involved with the child include:

  • Responding quickly to the child's death in accordance with the locally agreed procedures;
  • Maintaining a Joint Agency Response protocol with all agencies, consistent with the Kennedy principles and current investigative practice from the Association of Chief Police Officers;*
  • Making immediate enquiries into and evaluating the reasons for and circumstances of the death, in agreement with the coroner;
  • Liaising with the coroner and the pathologist;
  • Undertaking the types of enquiries/investigations that relate to the current responsibilities of their respective organisations;
  • Collecting information about the death (British Association for the Study and Prevention of Child Abuse and Neglect in Family involvement in case reviews, BASPCAN, see further information on involving families in reviews)
  • Providing support to the bereaved family, referring to specialist bereavement services where necessary and keeping them up to date with information about the child's death; and
  • Gaining consent early from the family for the examination of their medical notes.

The first professional on the scene must note:

  • The position of the child
  • The clothing worn, and
  • Circumstances in which the child was found.

Role of the Police at the Scene: Guidance

The provision of medical assistance to the child is the first priority. If an ambulance is not present ensure one is called immediately, and consider attempting to revive the child unless it is absolutely clear that the child is dead. Ensure that the officer in charge of the investigation is informed of any resuscitation attempts so they can inform the pathologist.

As at any incident, police officers must be aware of potential risks to health. These could include risk factors present at the scene but not obvious which could have contributed to the child's death and may endanger attending emergency services. For example there could be a carbon monoxide build up, faulty electrical appliances or the presence of chemicals. Each case must be assessed on its merits and appropriate expert advice taken prior to the officers approaching the body.

Normally the first officer attending the scene will be responding to an emergency call relating to a child's death. This officer will assume control of the situation and ensure the following actions take place:

  • If the child is dead preserve the body and location as a crime or road traffic collision scene;
  • Establish suitable cordons and limit access to the scene - Initiate a scene log;
  • Attendance at the body by medics should be via a common approach path;
  • Contact Control Room and request a supervisor is informed and attends - A decision will then be made about which specialist resource will attend;
  • In Road Traffic Collisions the duty Traffic SIO (Senior Investigating Officer) must be informed (normally of Sergeant rank). In the case of all other unexplained or suspicious deaths the duty Detective Inspector must attend the scene. If out of office hours the on call crime Senior Investigating Officer must be contacted - In cases of unexplained or suspicious child death the relevant duty SIO (crime or traffic) will ultimately decide on who has access to the scene and in consultation with the Coroner when the body will be removed.
  • The preservation of the scene and the level and type of investigation will be relevant and appropriate to the presenting factors.
  • The investigation of any suspicious or unexplained child death should follow the guidance in the ACPO Murder Investigation and ACPO Road Death Investigation Manuals, and the NPIA Core Investigative Doctrine.

Scene preservation and examination should follow the established techniques in those manuals.

There are a number of additional factors to consider with a child's death:

  • Retain items such as the child's used bottles, cups, food or medication;
  • The child's nappy and clothing should remain on the child but arrangements should be made for them to be retained at the hospital. If the nappy has already been removed from the baby prior to police arrival ensure that it is recovered from the parents and handed to the police - The nappy or clothing may be required for future laboratory examination. Any other clothing should only be retained if it is of evidential value;
  • If it is necessary to remove items from the house, do so with consideration for the parents. Explain that it may help to find out why their child has died. Ask the parents if they want the items returned;
  • Records of monitoring equipment from the Ambulance Service may be of evidential value and should be secured and preserved as this information may only be retained for 24 hours;
  • In cases of suspicious death the family will not be allowed access to the scene without the approval of the SIO. In all other cases the SIO must be consulted prior to the family being allowed access or continued access to any scene.

The above is NOT an exhaustive list of considerations and should be treated only as a guide.

Do record any environmental features that may have contributed to the child's death. Additionally record any evidence that indicates or could have contributed to the death such as temperature of scene, condition of accommodation, general hygiene and the availability of food/drink. Consider faulty appliances that may have caused the child's death.

Parents are likely to want to hold and touch the body of their loved one. Whilst fully understandable these wishes must be balanced against any potential forensic contamination. Most times this should be allowed, but only after consultation with the officer in charge of the investigation, and then only under supervision. 

Offer to contact friends or relatives who might support parents, and employers to explain absence.

Ultimately the purpose of any police investigation is to fully establish the circumstances leading to the child's death in order to assist the Coroner and / or the Crown Court.

Police Investigations

If the child has died at home or in the community, the lead police investigator and senior health care professional should decide whether there should be a visit to the place where the child died, how soon (ideally within 24 hours) and who should attend. This should almost always take place for cases of sudden infant death.

After this visit the senior investigator, visiting health care professional, GP, health visitor or school nurse and local authority children's social care representative should consider whether there is any information to raise concerns that neglect or abuse contributed to the child's death.

If there is a criminal investigation, the team of professionals must consult the lead police investigator and the Crown Prosecution Service to ensure that their enquiries do not prejudice any criminal proceedings. If the child dies in custody, there will be an investigation by the Prisons and Probation Ombudsman (or by the Independent Police Complaints Commission in the case of police custody). Organisations who worked with the child will be required to cooperate with that investigation.

The role of the GP: Guidance

There are times when a GP is called to the child first. In such circumstances the GP should adhere to the same general principles as the ambulance staff.

It is essential for the GP to contact the police or Coroner's officer if they are the first on the scene, after taking into account their primary responsibility of saving life or declaring death. The best route is the Police Call Centre.

A GP may not issue the death certificate in these circumstances. Children who have died without explanation should be seen in the A&E Department by a Consultant Paediatrician and not sent directly to the mortuary. This enables the clinical history, examination and any initial investigations to be completed and information given to parents.

Moving a child to the hospital or mortuary

In all cases where the body is taken directly to a hospital or a mortuary, arrangements must be made for a consultant paediatrician to be informed of the child's death, in order that an examination of the body can be made, tests arranged and medical information collated.

If the parents/carers wish to accompany the child's body from the home to the mortuary, then this should be facilitated, unless the death is viewed as unnatural. In all cases the body should be transported to the hospital either by paramedics or undertakers as appropriate.

Involvement of the coroner and pathologist where required

If a doctor is not able to issue a medical certificate of the cause of death, the lead professional or investigator must report the child's death to the coroner in accordance with a protocol agreed with the local coronial service. The coroner must investigate violent or unnatural death, or death of no known cause, and all deaths where a person is in custody at the time of death. The coroner will then have jurisdiction over the child's body at all times. Unless the death is natural a public inquest will be held. See Ministry of Justice guidance for coroners and Local Safeguarding Children Boards on the supply of information concerning the death of children.

The coroner will order a post mortem examination to be carried out as soon as possible by the most appropriate pathologist available (this may be a paediatric pathologist, forensic pathologist or both) who will perform the examination according to the guidelines and protocols laid down by the Royal College of Pathologists. The designated paediatrician will collate and share information about the circumstances of the child's death with the pathologist in order to inform this process.

If the death is unnatural or the cause of death cannot be confirmed, the coroner will hold an inquest. Professionals and organisations who are involved in the child death review process must cooperate with the coroner and provide him/her with a joint report about the circumstances of the child's death. This report should include a review of all medical, local authority social care and educational records on the child. The report should be delivered to the coroner within 28 days of the death unless crucial information is not yet available.

Phase One of Joint Agency Response : Immediate response to the unexpected death of a child taken to a hospital

On arrival the child should be taken to the appropriate resuscitation area and the paediatric resuscitation procedure should be initiated if appropriate.

The child must immediately be assessed by a senior paediatrician and death confirmed or appropriate resuscitation started; unless it is clear that the child has been dead for some time, resuscitation should always be initiated.

A qualified nurse must be allocated to look after the attending family and stay with the family, keeping them informed about what is happening. The identity of the people accompanying the child and their relationship to the child must be clarified by this nurse and recorded.

A detailed history should be taken during resuscitation by the Paediatrician, and as appropriate afterwards. Information must include a full medical history, a family history, history of any other child deaths, previous incidents of concern and an account of what happened and who was present. The history should be made available to the police.

When the child has been pronounced dead the Consultant Paediatrician should inform the parents/carers in attendance, having first reviewed all of the information available at that time.

The responsibility for further management and support of the family will usually rest with the Unexpected Death in Childhood Paediatrician (SUDIC Paediatrician) in conjunction with the police, social care, and other primary health care teams.

The SUDIC Paediatrician will collect all hospital records, including A&E sheets, for the child and other siblings in the family and make them available to the police for any subsequent post mortem and enquiries.

The SUDIC Paediatrician will start the process of notifying agencies that the child has died. They will contact the CDOP Coordinator as well as alerting key health and social care staff.

At this stage and until there has been a multi-agency Joint Agency Response meeting, the police press office will manage all media requests.

Assessment and investigation once the child has arrived at the A&E Department

As soon as possible after the arrival of the child at the A&E Department, the senior nurse on duty must ensure that the police have been contacted. The senior nurse on duty will also contact Customer Relations/Advice or EDT (if out of office hours) who should be asked to check records held by social care, including whether the child or siblings of the child are subject to a Child Protection Plan. 

Actions to be undertaken at the hospital: Guidance

  • The Consultant Paediatrician should examine the child. Any injury or superficial lesion should be documented on a body chart.
  • The family should be informed that the death must be notified to the coroner and that a post mortem will be required.
  • Core body temperature should be taken immediately on presentation, using a low temperature thermometer if necessary.
  • The site and route of any intervention in resuscitation needs to be carefully recorded.
  • The full growth measurement for all children and young people who have died should be plotted on a centile chart.
  • Some laboratory specimens may be taken during resuscitation, according to clinical need. In the case of SUDI there is a nationally agreed schedule of samples to be taken.
  • Details of samples should be clearly documented and the site of investigation should be recorded in the notes.
  • Further investigation such as skeletal survey will be done according to the coroner's wishes.
  • Intravenous and intra-arterial lines should not be removed unless agreed by the SIO. If any lines have been removed they should be retained as potential exhibits and their existence made aware to the police.
  • If an endotracheal tube has been inserted this should also be removed after its correct placement in the trachea has been confirmed by direct laryngoscopy (preferably by someone other than the person who inserted it). Again this should be retained as an exhibit if already removed.
  • Photographs of the child, prints of the hand and foot and a small lock of hair, as mementoes for the family, can be obtained following post mortem in most cases. As these samples are not taken before the post mortem, any wishes expressed by the family should be recorded.

Clothing must be left on the child. If removed to allow examination it should be placed in labelled specimen bags. Other items such as bedding brought in with the child should be placed in labelled specimen bags to be given to the Senior Investigating Officer. No items should be returned to the parents without consultation with the Senior Investigating Police Officer involved.

Before the family leave the Emergency Department the on-call Consultant Paediatrician should see them together with the Police SIO. In certain cases the police may wish to deploy a Family Liaison Officer who has a particular investigative role to perform. Wherever possible the SUDIC Paediatrician should also be present for this initial joint interview with the parents.

Written information, such as leaflets published by the Foundation for the Study of Infant Deaths, should be given to the parents at this time.

Review of the history and circumstances of the death by the Police SIO, on-call Consultant Paediatrician and, where possible, the SUDIC Paediatrician should take place.  Any child protection concerns for other children in the household must be discussed. If significant concerns emerge, this discussion will become the initial multi-agency strategy discussion under the Child Protection Section 47 Procedures.

Sudden unexpected death process

Unexpected Death Process


The Initial Home Visit

The Police SIO and SUDIC Paediatrician should make a decision about whether to visit the home or the site of the child's collapse or death. This should always take place for children who die unexpectedly.

They will decide if any other health care professional should be asked to attend, for example the GP, midwife, or health visitor. It is noted that the role this health professional took with the bereaved family in the pilot schemes was invaluable. This is usually the first time the family have returned to the scene and for some it may be the only time. If a Family Liaison Officer has been deployed by this stage they should attend.

The Police and SUDIC Paediatrician should consider in detail the events leading to the child's death along with the systematic examination of the site of the child's collapse/death.

The Paediatrician's role is to help to identify, understand and investigate factors that may have contributed to a natural, accidental or non-accidental cause of death and ensure that the pathologist is fully informed before starting the post mortem examination.

After the home visit the Police, SUDIC Paediatrician and any other professional who visited should review any significant concerns with regard to possible neglect or abuse having contributed to the child's death.

It is important to make detailed records of the history and examination findings, which must be dated and signed. As far as possible accounts should be recorded using the parent's/carer's own words.

Post Mortem, Pathologist and Coroner

If there are no suspicious circumstances, after an evaluation of initial information; from the ambulance service, hospital and previous records, primary care, police and social care records – the post-mortem should be conducted by a pathologist with special expertise in paediatric pathology. If possible the post-mortem should be completed within 48 hours of the child's death. If during the post-mortem the Pathologist becomes concerned that there may be suspicious circumstances, they must halt the post-mortem and inform the Coroner.

If the Coroner has any concerns that the death may be suspicious, then a Home Office Pathologist will be used in conjunction with a Paediatric Pathologist. Where a pathologist is qualified both as a forensic and Paediatric Pathologist they may complete the post-mortem on their own.

Although the results of the post mortem belong to the coroner, it should be possible for the Paediatrician, Pathologist, and the lead Police investigator to discuss the findings as soon as possible, and the coroner should be informed immediately of the initial results. If these results suggest evidence of abuse or neglect as a possible cause of death, the paediatrician should inform the police and local authority children's social care immediately. He or she should also inform the LSCB Chair so that they can consider whether the criteria are met for initiating an SCR.

Both the Coroner and the pathologist must be provided with a full history at the earliest possible stage. This will include a full medical history from the paediatrician, any relevant background information concerning the child and the family and any concerns raised by any agency. The police SIO is responsible for ensuring that this is done. A pro-forma is available for the paediatrician. The medical notes will also usually be sent/taken to the pathologist by the police officer attending the post-mortem. Depending on the circumstances of death this could be one of the investigating officers or the Coroner's Officer. Due to short timescales it is imperative all relevant information has been collected by the Paediatrician/ Nominated Nurse and handed to the police to take to the post mortem.

The Coroner's Officer should inform all relevant professionals of the time and place of the post-mortem, including the SIO and consultant paediatrician. The family should also be informed (via the FLO if one has been deployed).

The SIO should attend the post-mortem. If this is not possible, then he/she must send a representative who is aware of all of the facts of the case. In cases involving a Home Office Pathologist the SIO will decide appropriate resources to attend in line with the ACPO Murder Manual. As a minimum this would normally involve a CSI (Crime Scene Investigator), CSM (Crime Scene Manager) and exhibits officer. In all other cases the police will decide on the appropriate resources to attend.

The Pathologist at post-mortem will arrange a number of investigations.

If the paediatrician has arranged any medical investigations before or after death, the pathologist and Coroner must be informed and the results forwarded.

All professionals must endeavour to conclude their investigations expeditiously. This should include the post-mortem results such as histology. The release of the child's body is a matter for the Coroner in consultation with the SIO.

The interim or final findings of the post-mortem should be provided immediately after the post-mortem examination is completed and the Coroner updated. The interim result may well be 'awaiting histology/virology/toxicology'.

The police/Coroner's Officer will prepare a report for the Coroner once all information relevant to the investigation (including the pathologist's report) has been gathered. This report is intended to form the basis of a Coroner's inquest. The target timescale for the completion of this report is two weeks after the conclusion of the investigation.

When a child dies away from North Yorkshire and York

When a child who is normally resident in the North Yorkshire and York area dies out of their home area, the area in which the child dies will follow the process detailed in the relevant Local Safeguarding Children Board procedure.

All such deaths must be notified to the North Yorkshire and York Child Death Review Panel Coordinator as soon as possible after the child has been confirmed dead.

When a child living out of county is brought to a local hospital

When a child who lives out of the county dies in the area or where their body is brought to a local hospital (for example where they live just outside of the county), the North Yorkshire and York notification procedure will be followed. The Designated Doctor for Child death should contact their counterpart in the area in which the child is resident and send notification to the LSCB for that area. 

The LSCB managers for the two areas will decide which CDOP will review the child's death on a case-by-case basis. As a minimum the hospital paediatricians receiving the child will be required to provide a report to the LSCB, which will be forwarded to the LSCB of the area where the child was resident.

Phase Two Joint Agency Response (Within 5-7 days) The Initial Case Discussion

Shortly after the initial post mortem results become available, the designated paediatrician for unexpected child deaths may convene a multi-agency case discussion, including all those who knew the family and were involved in investigating the child's death. The professionals should review any further available information, including any that may raise concerns about safeguarding issues. A further multi-agency case discussion should be convened by the designated paediatrician, or a paediatrician acting as their deputy, as soon as the final post mortem result is available. This is in order to share information about the cause of death or factors that may have contributed to the death and to plan future care of the family. The designated paediatrician should arrange for a record of the discussion to be sent to the coroner, to inform the inquest and cause of death, and to the relevant CDOP, to inform the child death review. At the case discussion, it should be agreed how detailed information about the cause of the child's death will be shared, and by whom, with the parents, and who will offer the parents on-going support.

Phase Three Joint Agency Response (Within 8-12 weeks) The Multi-Agency Local Case Discussion Meeting

Once the results of all relevant investigations have been obtained, a multi-agency case discussion meeting is to be held. The meeting is convened and chaired by the Designated Doctor for Child Deaths and is formally recorded.

The purpose of the meeting is to:

  • Share information to identify the cause of death;
  • Identify those factors that may have contributed to the death;
  • Plan future care for the family;
  • Identify potential lessons to be learnt;
  • Inform the Coroner's inquest.

In cases of suspicious death the amount of information released from the police investigation to this meeting will be sufficient to inform on the above issues (it must be recognised there will be occasions where information cannot be disclosed due to on-going investigative concerns).

This meeting may involve the G.P., health visitor/school nurse/midwife, paediatrician, other relevant health professionals involved with the family, pathologist, senior investigating police officer, coroner's officer, social care manager, head teacher and any other relevant professionals.

The meeting should always consider the possibility of abuse or neglect. If no evidence is identified to suggest abuse or neglect as contributory factors this should be documented as part of the report of the meeting. The following should also be documented:

  • Any issues arising from the medical and social care given to the child and family;
  • Shortcomings in the medical and social care given to the child and family that may be identified;
  • Appropriate measures to improve future care;
  • Any issues of good practice.

The CDOP Form should be completed recording issues from this meeting.

Arrangements may be made for the SUDIC paediatrician and the GP or health visitor/school nurse/midwife to jointly see the parents to explain the content of this report and to address any further questions.

The meeting minutes should be sent to each of the agencies involved with a copy to the Coroner and the Child Death Overview Panel.

 The completed Child Death Agency Report should be forwarded to the Child Death Overview Panel.

The Child Death Overview Panel (CDOP) will undertake an overview of all deaths of children normally resident within North Yorkshire and the City of York. This will be a paper exercise based on the information available from those who were involved in the care of the child, before and immediately after the death. 

Eight key aspects of child deaths to be considered.

Child dies, notify the NYSCB CDOP Coordinator of all deaths

Key  consideration

Phase one: 0-5 days

Phase two: 5-7 days (initial PM)

Phase three: 8-12 weeks (final PM)

Key Consideration 1:
Care of families

Supporting families

Care and protection of siblings

Ensure support for

Informing parents, with reference to coronial
and criminal issues

Informing parents, subject to outcome of coronial and police enquiries

Key Consideration2:
Deciding on response

Expected and explained deaths, follow normal protocols

Follow normal protocols

Key Consideration3:
Joint Agency Response

Unexpected deaths: proceed to Joint Agency Response procedures: notify agencies, discuss and agree immediate action

Multi-agency case discussion/meeting

Multi-agency case meeting

Consider and agree on need for home visit

Refer to home visit record

Consider initial PM results

Consider final PM results

Notify coroner

Keep coroner informed

Report to coroner

Notify the police

Ensure planning consistent with police enquiries

Establish if any further police concerns

Notify health

Establish any clinical issues

Establish cause of death

Notify/check children's social care

Referral to children's social care should be made if questions arise regarding a child's protection

Notify CDOP

Inform CDOP on outcome of case discussion and/or meeting

Report to CDOP

Key Consideration4:

Child death information gathering and evaluation booklet

Key Consideration5:
Child protection

If children in need of protection, refer to Child Protection procedures

Key Consideration6:
Serious Case Review

Ask: does this require a Serious Case Review? Refer to LSCB to consider

Key Consideration7:
Media issues

The case discussion group will devise a media strategy and work with police to manage media enquiries

Ensure all involved aware of media strategy

Key Consideration8:
Support to staff

De-briefing of staff involved in the initial response to the child's death


Ensuring lessons are disseminated and any on-going support needs identified

Section 14: The Child Death Overview Panel


  • Public Health Consultant (Chairperson)
  • Safeguarding Children Board, North Yorkshire and York;
  • Designated Doctor (Child Deaths);
  • Designated Doctor (Child Protection) North Yorkshire and York;
  • Designated Nurse (Child Protection) or representative;
  • Social Care, North Yorkshire and York;
  • Police;
  • Education, North Yorkshire and York;
  • Coroner or representative;
  • Members co-opted as appropriate dependent on nature of review
  • Lay Members from the NYSCB and CYSCB

Additionally, the CDOP may request the attendance of any person who may provide specialist expertise or otherwise inform the work of the Panel.

The CDOP Process

Child Death Review Process


The Department for Education have provided Panels with a series of templates to collect information about children's deaths. These templates may be found on the Department for Education’s Website:

The notification form is also available on the websites of the North Yorkshire and York Safeguarding Children Boards at the following addresses:

North Yorkshire:

City of York

Preparation for the Child Death Overview Panel

In order to collate information for the CDOP meeting, when the CDOP Coordinator has been notified of the death of a child they will establish which agencies/professionals were involved with the child & family prior or at the time of death.

The CDOP Coordinator will forward the Agency Report Form B (part of the Department for Education’s set of templates) to all involved agency representatives/professionals to enable all relevant information on the child's case to be collected and collated to form a case summary. This will be compiled by the CDOP Coordinator from contributions from individual agencies. This acts as the "input data set" for the Child Death Overview Panel.

All representatives from each key agency should complete as much of the Agency Report Form as they are able, drawing on a review of the agency records and discussions with individual practitioners. Some aspects of the form are specific to individual agencies but all should be able to prepare summaries of relevant information available to them.

In addition to the narrative and questionnaire components of the Agency Report Form B, a brief summary should be available to include post mortem findings (where one has been conducted) and a full copy of the final post mortem report. For deaths of children in hospital or under the care of a secondary/tertiary team a copy of the final discharge/death summary is required.

Once all agency reports are received, the CDOP Coordinator will collate the information on to a Composite Form B. This then forms the case summary and input for the CDRP and will at this point be made anonymous.

Coroner's rules facilitate the sharing of information at local case review meetings. Where deaths are subject to coroner's investigations and/or inquests, coroner's officers will be invited to attend local case review meetings. The information made available in such cases will provide potentially valuable information to conduct the inquest which, in most cases, will take place after the case review meeting and before the CDOP that reviews the death.

The summary report from the local case review meeting should in all cases in which the coroner remains involved be copied to the coroner to help inform the inquest.


The Child Death Overview Panel

The CDOP meets on a bi-monthly basis to review individual cases; it:

  • Identifies gaps in information and seek clarification;
  • Collects and collates data in relation to all child deaths and report this to the North Yorkshire and City of York Safeguarding Children Boards on an annual basis;
  • Evaluates and classifies all child deaths, and undertakes in-depth reviews of selected cases.

Legal Considerations

Where there is an on-going criminal investigation or prosecution, the Police should be consulted as to what it is appropriate for the Panel to consider and what actions it might take, in order not to prejudice any criminal proceedings.

Categorising Death

The agenda of the CDOP is guided by the design of the national Analysis Proforma. It will involve:

  • A summary of the case prepared by the CDOP Coordinator along with the agreed cause of death.
  • The panel will then consider any relevant factors identified from agency reports in each of the following domains;
    • Factors intrinsic to the child;
    • Parenting capacity;
    • The family and environment;
    • Service provision

      The panel will consider the degree to which factors in each of these domains may have contributed to the death.

  • The CDOP will then categorise each death using a national assessment tool developed for the CDOP process. This will form part of the national core data set and enable analysis of information in relation to different types of death.
  • The CDOP will also make a decision on whether there are any modifiable factors in the death. This categorisation is to inform any effort to reduce childhood deaths and does not in itself carry any implication of blame on any individual party. It simply acknowledges where factors are identified which, had they been different, may have resulted in the death being prevented.
  • Once the assessment has been completed the panel will consider if there are any lessons to be learned, recommendations to be made or actions taken in response to the death.

A child death with modifiable factors is any case in 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 will consider modifiable factors, for example in the family and environment, parenting capacity or service provision, and consider what action could be taken locally, regionally and on a national level.

The main output from the CDOP will be to inform each Safeguarding Children Board’s Learning and Improvement Framework, to identify trends, improve the quality of practice, learning lessons and to identify multi-agency training requirements.

In Depth Reviews

The Safeguarding Children Boards may undertake or commission in-depth reviews when the assessment identifies issues that classify the case as avoidable or potentially avoidable but do not fit the criteria of a Serious Case Review. Such reviews provide the opportunity to make recommendations to other agencies regarding preventative actions that may be required in the future.

In-depth reviews will also be undertaken if patterns emerge in relation to a number of child deaths in order to gain a greater understanding of the issues and to establish any preventative measures that could be put in place.

Accountability and reporting lessons learned

The Child Death Overview Panel is responsible for developing a work plan, which should be approved by the LSCBs. It will prepare an annual report for the LSCBs, which are responsible for publishing relevant, anonymised information.

Where a trend or pattern of child fatalities is identified, and where it is assessed that action should be taken to avoid further deaths, the CDOP will make recommendations to the LSCB chairs at the earliest opportunity. On receiving the recommendations, the LSCB chairs should ensure appropriate action is taken by the respective agencies. However, the making of recommendations to the LSCB should not prevent the taking of any immediate action by individual agencies.

The LSCB takes responsibility for:

  • Disseminating the lessons to be learnt to all relevant organisations, ensuring that relevant findings inform the Children and Young People's Plan;
  • Acting on any recommendations to improve policy, professional practice and inter-agency working to safeguard and promote the welfare of children.

The NYSCB will supply anonymised data regularly on child deaths to the Department for Education.  This is to enable the Department to commission research and publish nationally comparable analyses of child deaths.

Confidentiality and information sharing

Information discussed at the CDOP meetings will be anonymised prior to the meeting by the CDOP Coordinator.

It is essential that all members adhere to strict guidelines on confidentiality and information sharing. Information is being shared in the public interest for the purposes set out in Working Together to Safeguard Children 2015, and is bound by legislation on data protection.

Last Review Date:
14 March 2018

Next Review Date:
14 March 2020

Notification of Child Death

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