Plymouth Safeguarding Children Partnership


Child Death

The Learning Approach




The death of a child is a devastating loss that profoundly affects bereaved parents as well as siblings, grandparents, extended family, friends and professionals involved in caring for the child in any capacity.     Families experiencing such tragedy should be met with empathy and compassion.    They need clear and sensitive communication.  They also need to understand what happened to their child and know that people will learn from what happened.   The process of expertly reviewing all children’s death is grounded in deep respect for the rights of children and their families with the intention of preventing future child deaths.


Child Death Review  


Under the Children Act 2004, as amended by the Children and Social Work Act 2017, the two child death review partners (local authorities and clinical commissioning groups) must set up child death review arrangements to review all deaths of children normally resident in the local area and, if they consider it appropriate, for any non-resident child who has died in their area.


In accordance with the statutory guidance Working Together to Safeguard Children (2018) child death review partners must make arrangements for the analysis of information from all deaths reviewed.


Child death review arrangements cover children aged under 18 years of age.   A child death review must be undertaken for all children regardless as to the cause of death.[1]  The purpose of the review and/or analysis is to identify any matters relating to the death or deaths that are relevant to the welfare of children in the area or to public health and safety, and to consider whether action should be taken in relation to any matters identified.  If child death review partners find action should be taken by a person or organisation they must inform them.   The flowchart on page 4 provides an overview of the child death review process.


Expected Child Deaths


If the child had a long-term illness or life-limiting condition and death was anticipated or inevitable it is likely the family and the multi-agency team supporting them will have made an appropriate care pathway together.   This may include an end of life care plan.



Unexpected deaths


An unexpected death is often sudden. Unexpected means not expected in the 24 hours before the death or the event that led to the death.      The law requires that all sudden and unexpected deaths are reported to the Coroner and the Police if the cause of death is not natural or unknown.   A Joint Agency Response will then be triggered.


Joint Agency Response (JAR)


A JAR is a coordinated multi-agency response by the named nurse, police investigator, and duty social worker and will be triggered if a child’s death:


  • is or could be due to external causes;
  • is sudden and there is no immediately apparent cause (including sudden unexpected death in infancy/childhood (SUDI/C);
  • occurs in custody, or where the child was detained under the Mental Health Act;
  • where the initial circumstances raise any suspicions that the death may not have been natural; or
  • in the case of a stillbirth where no healthcare professional was in attendance.


Immediate Response


The child will be transferred to the emergency department in hospital and will be examined by a paediatrician or other doctor and blood and samples will be taken.    Initial meetings between multi-agency professionals will take place.  Parents will be offered the opportunity for a memento, such as a lock of hair, or hand and foot prints of the child.


Joint home/scene visit


As soon as possible after the infant’s death, the named nurse and police investigator will visit the family at home or at the site of the child’s collapse or death. The purpose of this visit is to obtain further, more detailed information about the circumstances and environment in which the child died, and to provide the family with information and support.


This visit should normally take place within daylight hours. Unless there are clear forensic reasons to do so, the environment within which the child died should be left undisturbed so that it can be fully assessed jointly by the police and named nurse, in the presence of the family. Following this review, the named nurse should prepare a report of the initial findings to be made available to the pathologist, the coroner and the police investigator as soon as possible, and preferably prior to the post-mortem examination.


The post mortem examination


The aim of the investigation is to establish, as far as is possible, the cause of death. The investigation will concentrate not just on the child, but will consider the family history, past events and the circumstances. These factors can be helpful in determining why a child died. All parts of the process should be conducted with sensitivity, discretion and respect for the family and the child who has died. Once the final results of the post mortem and other clinical investigations are known, a child death review meeting is arranged to review emerging findings. This meeting should ideally take place before the inquest so as to inform the coroner’s investigation.


Child Death Review Meeting


This is a multi-professional meeting where all matters relating to an individual child’s death are discussed by the professionals directly involved in the care of that child during life and their investigation after death.


The nature of this meeting will vary according to the circumstances of the child’s death and the practitioners involved. A member of the child death review team will attend all appropriate child death review meetings in the acute and community settings. They will represent the ‘voice’ of the parents at these professional meetings, ensure that their questions are effectively addressed, provide feedback to the family afterwards and also ensure outcomes from the meetings are shared with the Child Death Overview Panel.


Child Death Overview Panel (CDOP)


This is a multi-agency panel set up by child death review partners to review the deaths of all children normally resident in their area, and, if appropriate and agreed between child death review partners, the deaths in their area of non-resident children, in order to learn lessons and share any findings for the prevention of future deaths. This review should be informed by a standardised report from the child death review meeting, and ensures independent, multi-agency scrutiny by senior professionals with no named responsibility for the child’s care during life.


The South West Peninsula has formed one Child Death Overview Panel covering Cornwall, Devon, Plymouth and Torbay.    Reviewing child deaths within this wider region, and larger population means the CDOP is better able to identify significant patterns of death and themes to aid future learning.   CDOP is responsible for reviewing information on all child deaths and are accountable the Child Death Partners.


Family engagement and bereavement support


Every family has the right to have their child’s death sensitively reviewed in order to, where possible, identify the cause of death and to ensure that lessons are learnt that may prevent further children’s deaths. Professionals have a duty to support and engage with families at all stages in the review process. Parents and carers should be informed about the review process, and given the opportunity to contribute to investigations and meetings, and be informed of their outcomes.

The processes that follow the death of a child are complex, in particular when multiple investigations are required. Recognising this, all bereaved families will be given a Child Death Review Nurse who will fulfil the role of single, named point of contact to whom they can turn for information on the child death review process, and who can signpost them to sources of support. Families should expect to be able to contact the child death review nurse during normal working hours. The leaflet When a Child Dies – A Guide for Parents and Carers should be given in printed format to all bereaved families or carers



[1] It does not include stillbirths, late foetal loss or terminations of pregnancy carried out within the law.