Appendix 11 - Child Deaths and Serious Case Reviews |
Contents
| 1.0 | Child Deaths |
| 2.0 | Unexpected Deaths |
| 3.0 | Child Death Overview Panel |
| 4.0 | Serious Case Reviews |
1.0 Child Deaths
The Wolverhampton Safeguarding Children Board will, in relation to the death of any child under the age of 18 years normally resident in the Wolverhampton area, collect and analyse information about each death with a view to identifying:
- Any matters of concern affecting the safety and welfare of children in the authority
- Any general public health or safety concerns
- Any case for which a Serious Case Review under Regulation 5 is needed.
The aggregated findings will be used to inform local strategic planning on how best to safeguard and promote the welfare of children in Wolverhampton.
2.0 Unexpected Deaths
An unexpected death is defined as the death of a child which was not anticipated as a significant possibility 24 hours before the death of the child or where there was a similarly unexpected collapse leading to or precipitating the events which led to the death.
In respect of each unexpected death there will be a rapid response review by the group of professionals involved with the child (before or after the death) to:
- Evaluate the reasons for and circumstances of the death in agreement with the coroner. Ultimately, the coroner is responsible for deciding whether abuse or neglect contributed to the child's death. Specialist tests and opinion may be required to inform this decision and there can be substantial delays between the child's death and the formal identification of its cause
- Undertake the enquiries/investigations which are the current responsibilities of the respective organisations when a child dies unexpectedly including liaising with those who have ongoing responsibilities for other family members
- Identify any case for which a Serious Case Review under Regulation 5 is needed. The Deputy Head of Safeguarding will instigate the process agreed by the Wolverhampton Safeguarding Children Board to decide whether a Serious Case Review should be held.
Unexpected death investigations should:
- Maintain an appropriate balance between forensic/medical requirements and the family's need for support. Whatever the circumstances of the child's death, the family's need for support in their bereavement, including that of any siblings, should not be overlooked
- Address the possible needs of other children in the household
- Address the needs of all family members
- Approach enquiries with an open mind
- Treat families with sensitivity, discretion and respect at all times
- Identify a professional to provide support to the parents/carers
- Initiate an investigation under Section 47 if concerns are raised that there is a possibility of abuse or neglect. Consider the need to convene a child protection conference in respect of siblings or any other child in the same household.
- Initiate a Child In Need assessment if concerns are raised about the needs of any surviving children
Certain factors in the history or examination of the child may give rise to concern about the circumstances surrounding the death:
- Previous child protection concerns in the family relating to this child or siblings
- Previous child deaths
- Inappropriate delay in seeking medical help
- Inconsistent explanations or accounts given by the parents in respect of the circumstances of the death- although it is important to consider that some inconsistencies may occur as a result of the shock and trauma caused by the death;
- Evidence of parental substance misuse - in particular if the parents were intoxicated at the time of death;
- Evidence of parental mental ill health including evidence of previous fabricated or induced illness
- Unexplained injuries to the child;
- Neglect; concern about home conditions, standards of hygiene and cleanliness, availability of food, adequacy of clothing and bedding and the temperature of the environment in which the child was found.
The procedure to be followed following an unexpected death is:
- Unless the circumstances of the death require the body to remain in situ, the child's body will normally be taken to A&E unless the death has occurred in hospital
- The consultant paediatrician will take a detailed history from the parents/carers following a nationally agreed data set and conduct any specialist tests required as agreed with the coroner
- Once the death is confirmed, the parents should be informed and future police and coroner involvement explained including the possibility of a post mortem and the removal of tissues for analysis
- The designated paediatrician with responsibility for unexpected deaths in childhood should be informed at the same time as notification to the coroner
- The on call or designated paediatrician should initiate immediate information sharing and planning between the involved agencies
- A decision should be made about whether a visit should be made to the place where the child died for those children who died in a non hospital setting. This visit will normally be undertaken, either jointly or separately, by the senior investigating police officer and a health care professional and will take place within 24 hours. The purpose of the visit is to talk with the parents and to inspect the scene in order to collect information about the possibility of abuse or neglect having contributed to the death
- All information collected relating to the circumstances of the death including a review of all relevant medical, social and educational records must be included in a report to the coroner within 28 days of the death and must be shared with the pathologist conducting the post mortem
- Following the post mortem a further multi agency discussion should be convened by the designated paediatrician for unexpected deaths, usually within 5 - 7 days of the death to review any further information which has come to light
- The designated paediatrician with responsibility for unexpected deaths should convene and chair a case discussion meeting of all those involved with the child and the investigation of the death as soon as the final post mortem result is available This may happen from immediately after the post mortem to 8 to 12 weeks after the death. The purpose of the meeting is to share information to identify the factors that may have contributed to the death; to plan the future care of the family; to agree how detailed information about the cause of death will be shared with the parents/carers and by who; and to identify lessons which can be learnt
- An agreed record of the meeting and all reports should be sent to the coroner. The record of the meeting and the core data set should also be made available to the local Child Death Overview Panel.
3.0 Child Death Overview Panel
See detailed procedures and links to notification forms on the Wolverhampton SCB Website – Child Death Overview Panel.
The Wolverhampton Safeguarding Children Board will be informed of all deaths of children normally resident in the city of Wolverhampton. The Child Death Overview Panel will meet regularly to undertake a paper review of all these deaths to:
- Review the appropriateness of the professional's response to each unexpected death
- Monitor the collection of data and identify any patterns or trends in local data
- Identify any public health issues
- Review the effectiveness of inter-agency working to safeguard and promote the welfare of children
- Consider whether any death should be subject to further investigation or a Serious Case Review
- Monitor the support and assessment services offered to families of children who have died
- Consider any training needs arising from the review of cases
4.0 Serious Case Review
When a child dies (including death by suicide), and abuse or neglect are known or suspected to be a factor in the death, agencies need to consider whether there are any lessons to be learned from the tragedy about the ways in which the agencies work together to safeguard children. Consequently when a child dies in such circumstances, Wolverhampton Safeguarding Children Board will always conduct a Serious Case Review of the involvement of agencies and professionals with the child and family
Additionally, the Wolverhampton Safeguarding Children Board will always consider whether a Serious Case Review should be conducted:
- When a child sustains a potential life-threatening injury or serious and permanent impairment of health and development;
- When a child has been subjected to particularly serious sexual abuse, and the case gives rise to concerns about inter-agency working to protect children;
- When a parent has been murdered;
- When a child has been killed by a parent With mental illness.
A Serious Case Review may also be considered if several of the following factors are present in a case:
- Evidence of risk of Significant Harm was not recognised or acted on appropriately by organisations in contact with the child; or an agency feels its concerns were not taken sufficiently seriously by another agency; or the case has implications for a range of agencies;
- The child was abused in an institutional setting or while looked after by the local authority;
- The child died in a custodial setting;
- The child committed suicide or died while missing from home;
- The child was subject of a Child Protection Plan or had previously been the subject of a child protection plan;
- The case indicates failings in the safeguarding children procedures which go beyond the handling of the individual case.
The purpose of the Case Review is to improve inter-agency working and to better safeguard children by:
- Establishing whether there are lessons to be learned from the case about the way in which local professionals and agencies work together to safeguard children;
- Identifying clearly what those lessons are, how they will be acted upon, and what is expected to change as a result.
Case Reviews are not enquiries into how a child died - that is a matter for the Coroner - and if appropriate the Courts - to determine.
When it is thought that a child matches the criteria for a Serious Case Review this should be brought to the attention of the Chair of the Wolverhampton Safeguarding Children Board as a matter of urgency.
The Chair of the Wolverhampton Safeguarding Children Board should refer the case to the Serious Cases Review Panel as soon as preliminary enquiries indicate that the criteria for a serious case review may be satisfied.
The Serious Cases Review Panel will be chaired by a person nominated by the Wolverhampton Safeguarding Children Board and the core membership will include the following personnel:-
- Consultant Community Paediatrician - Designated Doctor;
- Child Protection Adviser - Designated Senior Nurse;
- DCI or DI, Police Authority;
- Principal Officer, Child Protection;
- Principal Officer, Education;
- Solicitor, Legal Services, Wolverhampton City Council.
Other members may be appointed as required. The terms of reference for the Serious Cases Review Panel are to:
- Recommend to the Chair of the LSCB whether the case meets the criteria for a Serious Case Review. This recommendation of the Panel and decision by the Chair of the Wolverhampton Safeguarding Children Board to conduct a Serious Case Review should be made within one month of the case initially being brought to the attention of the Chair of the Wolverhampton Safeguarding Children Board;
- Determine the scope and timescale of the review and initiate individual Management Reviews;
- Agree individual Management Reviews by specified agencies when a full Serious Case Review is not required;
- Receive and consider findings and recommendations of individual Management Reviews;
- Complete the Serious Case Review within four months of the decision by the Chair of the Wolverhampton Safeguarding Children Board to undertake the review unless an alternative timescale has been agreed with the Commission for Social Care Inspection;
- Monitor and implement any actions arising from individual Management Reviews and/or Serious Case Review Action Plans.
Issues to consider in determining the scope of the Case Review are:
- What are the most important issues to address and how can information be obtained?
- Is any independent expert advice required?
- How should family members be involved?
- How will any media interest be managed?
- Will there be any parallel investigations and how can these be co-ordinated?
All key agencies should have a named individual responsible for Serious Case Reviews. The person co-ordinating the Individual Management Review or producing the Overview Report should not have been directly involved with the child/ren or family or the immediate line manager of the practitioner(s) concerned.
Once it is known that a case is being considered for review, each organisation should secure records relating to the case to guard against loss or interference.
The format for the Individual Management Review should include the following:-
- A description of the involvement of the agency with the child/ren and family;
- An analysis of the agency's involvement;
- An examination of the lessons which can be learned from the case;
- Recommendations for action.
An independent person will be commissioned to bring the Individual Management Reports into an Overview Report containing recommendations.
The Overview Report should be presented to the Wolverhampton Safeguarding Children Board for adoption. An Action Plan should be presented at the same time, and should be endorsed at a senior level in each agency involved.
Both following individual Management Reviews and the Overview Report arrangements should be made for feedback to and de-briefing of staff.
The Deputy Head of Safeguarding will formally notify the Commission for Social Care Inspection when Serious Case Reviews are undertaken and a copy of the Overview Report will be provided to the Commission for Social Care Inspection and to the Department for Education and Skills.End