8.1 Child Death Review Process (including Rapid Response Process and Child Death Overview Panel Process)

Contents

1. Background
2. Definitions
3. Population Reviewed by Oxfordshire’s Child Death Review Process
4. Principles for Providing Parents with Support
5. Unexpected Death in the Community
6. Unexpected Death in an Oxfordshire Hospital
7. The Rapid Response Process (RRP) for Unexpected Child Death
8. Information Collected for the Child Death Review Process
9. Child Death Overview Panel
10. Confidentiality
11. Key Personnel in the Child Death Review Process

1. Background

From April 2008, the Oxfordshire Safeguarding Children Board (OSCB) has a statutory duty to ensure all deaths of Oxfordshire children aged 0 – 18 years are reviewed.

The aim of the review is to collect and analyse information about deaths to identify:

1. cases requiring a Serious Case Review
2. matters of concern affecting the safety and welfare of children
3. any wider public health or safety concerns arising from a particular death or from a pattern of deaths in the area

It is anticipated the process will result in a more coordinated professional response to unexpected child deaths and improved support for bereaved families.

The Child Death Review Process involves the Rapid Response Process and the Child Death Overview Panel.

The Rapid Response Process (RRP) (which is set out in Section 7, The Rapid Response Process (RRP) for Unexpected Child Death) is a prompt, coordinated response by key professionals to the unexpected death of a child.

The Child Death Overview Panel (CDOP) (which is set out in Section 9, Child Death Overview Panel) reviews the deaths of all children (expected and unexpected) some months after the event.  The CDOP is a subgroup of the OSCB. 

2. Definitions

An unexpected death is the death of a child which is 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 lead to the death.  The definition includes all accidental deaths and deaths following suicide; it excludes situations where treatment is withdrawn or replaced with palliative care in a child with a long standing medical condition.

Natural causes of death include all disease processes and congenital anomalies.

Non-natural causes of death include road traffic accidents, drowning, fire/burns, fall, poisoning, substance misuse, suicide, homicide.

3. Population Reviewed by Oxfordshire’s Child Death Review Process

The Oxfordshire Child Death Process considers the deaths of children resident in Oxfordshire, wherever they die.

4. Principles for Providing Parents with Support

• When a child dies, the child’s parents should be allocated a staff member to remain in contact with them throughout the process
• Parents should be kept up-to-date with information about their child’s death
• Parents should be informed about the Child Death Review Process

5. Unexpected Death in the Community

1. Infants/children who die unexpectedly at home should be taken to the Emergency Department (ED) of the local hospital rather than to a mortuary and resuscitation initiated unless clearly inappropriate.
2. The ambulance service should notify the police and relevant hospital immediately when called to the scene of an unexpected child death.
3. Ambulance staff must wait for police clearance before taking the body to the ED. If police have reason to believe that death occurred in suspicious circumstances, immediate removal of the child’s body may not be appropriate
4. When a child is certified dead in the community, it may not be appropriate to use the ambulance service and the police will arrange for the body to be taken to the mortuary
5. Where a child is not taken to the ED, the professional certifying death must inform the designated paediatrician with responsibility for the Rapid Response Process (RRP) (see Section 7, The Rapid Response Process (RRP) for Unexpected Child Death) at the same time as informing the coroner.

6. Unexpected Death in an Oxfordshire Hospital

(This applies to all hospitals i.e. the Children’s Hospital, the John Radcliffe Hospital, the Horton General Hospital, the Churchill Hospital or the Nuffield Orthopaedic Centre).

1. When resuscitation is abandoned the consultant in charge should be informed, if not already aware.
2. If the child is under 2 years, the Sudden Unexpected Death in Infancy Protocol should be completed and notification of the death made to those listed in the protocol (the protocol is available on the Children’s Hospital website), including the designated paediatrician.
3. If the child is over 2 years old, the coroner, police, the child’s GP and the designated paediatrician should be notified.
4. The consultant in charge should advise the parents that a police officer may need to speak to them before they leave hospital and that the child is likely to have a post mortem (PM) examination.
5. The consultant should inform the parents they will be kept up to date with information about their child’s death and that in due course be offered an appointment for discussion about the final PM report.

7. The Rapid Response Process (RRP) for Unexpected Child Death

7.1.  Objectives

The RRP, through a comprehensive and multi-disciplinary review of all unexpected child deaths, will:

• identify those cases to be considered for a Serious Case Review
• complete the data set on all unexpected deaths for the Child Death Overview Panel (CDOP) (see Section 9, Child Death Overview Panel)
• identify those unexpected deaths which are non-natural, and collect  information  for detailed case consideration by the CDOP
• ensure bereaved families are appropriately supported and are kept informed about the cause of their child’s death

7.2   Process

7.2.1 Notification of the unexpected death of a child

The following professionals should notify the designated paediatrician about an unexpected child death:

• consultant paediatricians, consultant surgeons, consultant physicians, and other doctors certifying a child’s death in unexpected circumstances
• coroner’s officers
• consultant pathologists
• the police

Multiple notifications are requested to ensure full ascertainment.

Notification should include basic information about the child, the nature of the death and the name of the child’s GP.

Telephone no. for notification - 01865 231959

7.2.2  Planning Discussion

Following a discussion between key professionals (designated paediatrician, consultant in charge of the child, +/- police, coroner’s officer, consultant pathologist, social care manager), a decision is made as to whether a Strategy Meeting is indicated. Not all unexpected deaths have a Strategy Meeting.

At this stage consideration is given to the need for a Serious Case Review (to be organised by the OSCB) and/or a Serious Untoward Incident (SUI) meeting – (to be organised by the Oxford Radcliffe Hospital Trust).

7.2.3 Strategy Meeting

Strategy Meetings are held on most young children (under 2 years) who die unexpectedly at home. The meeting takes place a few days after the child’s death when the initial PM results are available.

The purpose of the meeting is:

• to share information about events leading to the child’s death
• to provide background history for the pathologist
• to ensure a coordinated bereavement plan for the family
• to consider any child protection risks/ need for a Serious Case Review     

The meeting is chaired by the designated paediatrician.

The child’s consultant, GP, health visitor and midwife; the pathologist; the specialist  health visitor; the senior nurse from the ED; the coroner’s officer; a police representative; a senior social care manager; the ambulance crew; the administrator and other relevant professionals are invited.

At the meeting information about the child is collected for the data set and it is agreed which doctor will go through the final PM findings with the parents.

Parents are informed about the meeting.

7.2.4 Case discussion meeting following final PM results

The case discussion takes place 8 – 12 weeks after the child’s unexpected death when the final PM result is available. The meeting is chaired by the designated paediatrician. It is attended by 2 paediatricians, a paediatric intensive care consultant, the paediatric pathologists, a senior coroner’s officer, the specialist health visitor, the senior ED nurse, a senior police officer from the Child Protection Unit (CPU), a senior social care manager and the administrator. Representation from the child’s primary care team and others from education/ the community is sought as appropriate. 

The purpose of the meeting is: 

• to share information to identify the cause of death and/ those factors which may have contributed to the death
• establish whether the unexpected death was ‘natural’ or ‘non-natural’
• correct any inaccuracies and complete the data set
• to review support for the family

The data set on unexpected child deaths is forwarded to the Child Death Overview Panel (CDOP).

All information on unexpected ‘non-natural’ deaths is forwarded to the CDOP for further consideration.

8. Information Collected for the Child Death Review Process

Every Child Matters/DCSF Forms A – E

9. Child Death Overview Panel

9.1   Responsibilities

The responsibilities of the Child Death Overview Panel are to:

9.1.1 Collect and analyse information

from:

1. the Rapid Response Process (RRP) on unexpected child deaths
2. the  local CEMACH (Confidential Enquiry into Maternal and Child Health) coordinator on neonatal deaths (0-28 days)
3. the Registrar of Deaths/other sources on expected deaths

9.1.2 Organise and monitor

the collection of data for the nationally agreed minimum data set and make recommendations to the Oxfordshire Safeguarding Children Board (OSCB) for any additional data to be collected locally;

9.1.3 Scrutinise

the information about each death with a view to identifying:

1. Any case giving rise to the need for a serious case review
2. Any matters of concern affecting the safety and welfare of children in the area of the authority;
3. Any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area;

9.1.4 Review

a limited number of cases in more detail                               

9.1.5 Recommend

to the OSCB procedures for ensuring that there is a coordinated response by all Board partners and other relevant persons to an unexpected death.

9.2   Process

The Child Death Overview Panel (CDOP) will:

9.2.1	undertake a paper exercise, based on information available from those who were involved in the care of the child both before and immediately after the death and other sources, including the coroner;
9.2.2	collect and collate an agreed minimum data set and, where relevant, seek information from professionals and family members;
9.2.3	meet to evaluate the routinely collected data on the deaths of all children and thereby identify issues of concern or lessons to be learnt with a particular focus on effective inter-agency working to safeguard and promote the welfare of children;
9.2.4	develop an appropriate mechanism to evaluate, where necessary, specific cases in depth, at subsequent meetings;
9.2.5	monitor the appropriateness of the response of professionals to an unexpected death of a child, reviewing the reports produced by the rapid response team on each unexpected death of a child, making a full record of this discussion and providing the professionals with feedback on their work;
9.2.6	review the appropriateness of the professionals’ response to each unexpected death of a child , their involvement before the death, and relevant environmental, social, health and cultural aspects of each death, to ensure a thorough consideration of how such deaths might be prevented in the future;
9.2.7	provide relevant information to those professionals involved with the child’s family, so that they in turn can convey this information in a sensitive and timely manner to the family;
9.2.8	refer to the Chair of OSCB any deaths where, on evaluation of the available information, the Panel considers there may be grounds to undertake further enquiries, investigations or a Serious Case Review and explore why this had not previously been recognised;
9.2.9	inform the Chair of the OSCB where specific new information should be passed to the Coroner or other appropriate authorities;
9.2.10	identify any patterns or trends in the local data and report these to the OSCB;
9.2.11	advise the OSCB on the resources and training required locally to ensure an effective inter-agency response to child deaths;
9.2.12	identify any public health issues and consider with the Director of Public Health how best to address these and their implications for both the provision of services and for training;
9.2.13	cooperate 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

NB Where there is an ongoing criminal investigation, the Crown Prosecution Service must be consulted as to what it is appropriate for the Panel to be considering and what actions it might take in order not to prejudice any criminal proceedings.

10. Confidentiality

Information discussed at the RRP meetings and the CDOP is not anonymised.

Members should adhere to guidelines on confidentiality and information sharing.  Information is being shared in the public interest for the purposes set out in Working Together and is bound by legislation on data protection – see Information Sharing Protocol.

11. Key Personnel in the Child Death Review Process

The Oxfordshire Child Death Review Process administrator is Julianne Exley who assists with data collection of child deaths and supports the Rapid Response Process (RRP) and the Child Death Overview Panel (CDOP).

The RRP is led by Dr. Claire Burns, designated consultant paediatrician (deputies Dr. Janet Craze and Dr. Leighton Phillips, consultant paediatricians).

Catherine Ebbs, Specialist Health Visitor (HV) provides advice to Primary Care on support for bereaved families.

The CDOP is chaired by Dr. Ljuba Stirzaker, consultant in public health.

Contact numbers of Key Personnel

Post	Name	Contact Details
Notification of an unexpected child death		01865 231959
Administrator	Julianne Exley	01865 231974 Julieann.Exley@oxfordshirepct.nhs.uk
Designated paediatrician	Dr. Claire Burns	01865 231972/231997
Deputy Designated paediatrician	Dr. Janet Craze	01865 231302
Deputy Designated paediatrician	Dr.  Leighton Phillips	01993 229510
Specialist Health Visitor	Catherine Ebbs	01491 833191
Chair, Child Death Overview Panel	Dr. Ljuba Stirzaker	01865 336722

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