9.2.1 Notifications and Recording of Information in Relation to Child Deaths

SCOPE OF THIS CHAPTER

The following procedures are to be followed where any child or young person up to the age of 17 and 364 days dies (excluding those babies who are stillborn or planned terminations that are within the law but including children with life-long or life limiting conditions) where the child was normally resident in Solihull, or where the child's cause of death originated in Solihull. The procedures apply both to expected and unexpected deaths.

AMENDMENTS

This chapter has been amended to take account of the changes in Chapter 7 of Working Together to Safeguard Children 2010. The changes, which are shown in italics in Sections 1, 2, 4 and 7, reflect the changes in Chapter 5 of WT 2010.

Introduction
Information Sharing
Documentation
Initial Notification and Completion of Form A
Data Collection and Completion of Form B
Analysis and Completion of Form C
Audit
Forms

1. Introduction

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

a rapid response by a group of key professionals who come together for the purpose of enquiring into and evaluating each unexpected death of a child (see West Midlands Best Practice Multi Agency Protocol for the Management of Sudden Unexpected Deaths in Infants and Children under 18 (SUDC)); and
an overview of all child deaths (under 18 years old) in the Solihull area, undertaken by a Review Panel (see Child Death Review Panel and Overview Panel Processes)

This chapter sets out the notification and recording procedures to be followed where any child or young person up to the age of 18 years dies (excluding those babies who are stillborn or planned terminations that are within the law but including children with life-long or life limiting conditions) where the child was normally resident in Solihull, or where the child's cause of death originated in Solihull. The procedures apply both to expected and unexpected deaths.

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 led to the death

2. Information Sharing

2.1	Under Regulation 6 of the Local Safeguarding Children Regulations 2006, Local Safeguarding Children Boards (LSCB) have a statutory responsibility to collect and analyse information about each child death with a view to identifying: any case giving rise to the need for a Serious Case Review - see Serious Case Review Procedure any matters of concern affecting the safety and welfare of children in their area any wider public health or safety concerns arising from a particular death or from a pattern of deaths in their area.
2.2	The disclosure of information about a deceased child is therefore to enable the LSCB to carry out its statutory functions relating to child deaths.
2.3	Information shared with other professionals, namely members of the Child Death Review Panel, is shared again to enable the LSCB to carry out its statutory functions. Much of this information is protected from public disclosure under Data Protection legislation. The Child Death Review Panel will promote the confidentiality of any sensitive and personal data.

3. Documentation

There are three key stages of documentation to support the child death review processes:

Form A: Initial Notification Form
Form B: Agency Report / Case Record - a case summary to be compiled in a local case review or by the Child Death Review Manager from contributions from individual agencies. This acts as the "input data set" for the Child Death Review Panel.
Form C: Analysis Proforma, which is the "output" from the Child Death Review Panel.

4. Initial Notification and Completion of Form A

Responsibility to make an initial notification

4.1	The professional who confirms the death of a child or young person (excluding those babies who are stillborn or planned terminations that are within the law), where the child was normally resident in Solihull, or where the child's cause of death originated in Solihull, must ensure that the Child Death Review Manager is notified. In unexpected deaths this will be at the same time they inform the coroner
Potential Sources of notification
4.2	Potential sources of notification include Solihull Care Trust staff Registrar of Births, Deaths and Marriages The Coroner Accident and Emergency Departments Acute Trust Staff Police General Practitioners Ambulance Service Fire Service Any other agency Members of the public
How to make a notification
4.3	Any professional notifying the Child Death Review Manager/Administrator of a child death should do so by completing the Initial Notification Form (Form A) faxed to the Child Death Review Manager/Administrator (01926 742394)
4.4	Individual professionals confirming the fact of the child's death will notify the Child Death Review Manager at the same time that they notify the Coroner and / or child health records within Solihull Care Trust.
Cross Boundary Issues
4.5	If the Child Death Review Manager is notified about the death of a child/young person normally resident outside of Solihull the Manager should notify his or her counterpart in the area of the child/young person's normal place of residence. For deaths occurring in another area when the child’s normal residence was in Solihull, the local CDOP would lead the Child Death Review and a case by case decision must be reached between the two Child Death Overview Panel Chairpersons as to how the other Panel will be notified of the outcome or involved in the review.
Serious Case Review Criteria
4.6	Any professional who is aware of the death of a child/young person must consider whether the criteria for a Serious Case Review may apply. If it is considered that they may apply, the Chair of the LSCB should be contacted immediately and the Serious Case Review Procedure must be followed. This includes the need to consider the immediate safety and welfare of other children/young people.

5. Data Collection and Completion of Form B

Core Data Set

5.1	The Child Death Review Manager will maintain a database of all child deaths and information will be collected in accordance with the nationally agreed minimum dataset as follows.
Informing Relevant Agencies of the death of a child
5.2	On receipt of a notification of a child death, the Child Death Review Manager will promptly attempt to confirm this information by contacting the relevant local agencies that may have been involved. It is important at this stage to obtain as much information as possible - including information on all members of the household, and identifying all key professionals.
Completion of Form B (Agency Report Form / Case Record)
5.3	The Child Death Review Manager / Administrator will forward a copy of Form B (Agency Report Form / Case Record) to agency representatives for their completion. In order to ensure completeness and accuracy of the information all representatives from each key agency should complete as much as they are able of Form B, drawing on a review of their agency records and discussions with individual practitioners. Some aspects of the form are specific to individual agencies (e.g. health), but all agencies should be able to prepare summaries of relevant information available to them. Additional information to populate the agreed minimum dataset may be obtained by the Child Death Review Manager/ Administrator via direct contact with individual agencies / professionals.
5.4	There are 6 sections in Form B Identifying and Reporting Details This section will normally be completed by the Child Death Review Manager / Administrator from the Notification Form (Form A) prior to sending out to agency representatives. This identifying information can be separated from the rest of the form in order to anonymise the case prior to distribution to the Child Death Review Panel members. Summary of Case and Circumstances leading to the Death Information is included on the nature and circumstances of the death. For some specific categories of death (e.g. road traffic accidents, apparent suicides, SUDI) further specific information will be gathered as part of the core data set. Additional forms will be distributed as appropriate. As well as the core data items, narrative information on the circumstances leading to the death is included to inform the understanding of the case The Child Parenting Capacity Family and Environment Service Provision
5.5	Each of these sections contains specific data items as well as space for narrative accounts of the relevant factors relating to the child's death.
5.6	In addition to the narrative and questionnaire components, the form should include a brief summary of the relevant positive and negative findings from the post mortem examination (Form B-11), (where one has been conducted) as well as a full copy of the final post mortem report and (for deaths of children in hospital or under the care of a secondary/tertiary care team) a copy of the final discharge / death summary.
5.7	Once all agency reports are received, the Child Death Review Manager should collate the information onto one form. This collated Form B then forms the case summary and input to the Child Death Review Panel, and can at that point be anonymised. Where there are any discrepancies or disagreements between agencies as to any of the factual information, this should be noted and where possible, consensus reached.
5.8	Recent changes to the coroners' rules facilitates the sharing of information (particularly police reports and post mortem reports) at this meeting for those deaths subject to coroners' investigations and/or Inquests. For all such deaths, the coroner or coroner's officer should be invited to attend the final case discussion meeting (as recommended in Chapter 7 of "Working Together"). The information made available, the discussions, and the outcome of the final case discussion meeting in such cases will provide potentially valuable information to inform the conduct of the inquest, which it is anticipated in most cases, will take place after the final case discussion meeting but before the Child Death Review Panel meeting 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.

6. Analysis and Completion of Form C

6.1	The analysis of the case should be recorded on Form C - Analysis Proforma. The first page provides for identifying details of the case. These details should be removed and replaced by a unique identifier if the Panel is discussing cases anonymously, and in any event should be removed after the Panel meeting in order to ensure that any outputs from the panel are anonymised.
Unexpected Deaths
6.2	In unexpected deaths, the first five pages of Form C should be completed at the Final Case Discussion. Consideration should be given to the degree to which any of the following factors may have contributed to the death. Factors intrinsic to the child Factors in the family and environment Factors in the parenting capacity Factors in relation to service provision
6.3	Page 5 of Form C is a categorisation of the child's death using a scheme developed for the Child Death Review process. This classification is hierarchical: where more than one category could reasonably be applied, the highest up the list should be marked. This will form part of the national core data set and enable analysis of information in relation to different types of death.
6.4	The remainder of Form C will be completed by the Child Death Review Panel, which will make a decision on the degree to which each death is considered preventable. It is important to recognise that this categorisation is to inform any efforts to reduce childhood deaths. It does not in itself carry any implication of blame on any individual party, but simply acknowledges where factors are identified which, had they been different, may have resulted in the death being prevented.
6.5	The final section of the form allows the Child Death Review Panel to identify any lessons to be learnt, recommendations to be made or actions to be taken in response to the review of the death. It is anticipated that in most cases, any individual action in relation to specific case management will have been identified and addressed through the local case discussions or other related processes; the focus of these actions and recommendations are on lessons to be learnt at a population level. The Review Panel will have the advantage of being able to review each individual child death in the context of other deaths of children in the area, and to be able to identify any potentially contributory recurrent themes, circumstances, or possible limitations in service provision by one or more agencies. The main public output from the Review Panel will be in an annual report - drawing on the information from individual cases and from the overall pattern of events, contributory factors and service provision in their local area. Recommendations regarding action required to reduce childhood deaths can also be included in the annual report.
Expected Deaths
6.7	Where the death is expected the whole of Form C will be completed at the Review Panel.