Timeline: After Emergency Department

The senior investigating police officer and senior healthcare professional decides whether there needs to be a home visit, how soon this needs to occur (usually within 24 hours) and who should attend.

Following this, within the first 48 hours, there is then an Initial Multiagency Meeting which is led by one agency. It can take many months to gather all of the information required, but the purpose of this initial meeting is to:

  • Share the initial information available, including the medical history and examination.
  • Determine what further information may be needed and who is tasked with gathering it.
  • Consider whether there are any immediate child protection concerns to be actioned (e.g. to other siblings).
  • Consider whether there are any health risks to other family members that have not yet been addressed.
  • Arrange support for the family.

In all SUDIC cases, the lead health professional reports the child’s death to the Coroner as per local protocol. The Coroner then has jurisdiction over the child’s body and will order a post-mortem by a Pathologist. Information collated by the Paediatrician attending the child is shared with the Pathologist at this point.

Once the initial post-mortem results become available, the designated paediatrician for unexpected child deaths holds a local multiagency case discussion, where the information is reviewed again in case any concerns are raised about safeguarding issues.

If the cause of death cannot be ascertained, or is unnatural, the Coroner holds an inquest, where those involved in the Child Death Review Process submit a joint report about the circumstances of the child’s death, to include a review of all medical, social care and educational records on the child.

At the end of this entire process, all child deaths in England are reviewed by the Child Death Overview Panel (CDOP) which is established by the Local Safeguarding Children Partnership (LSCP).

What is the child death overview panel?

The CDOP is responsible for:

  • reviewing all child deaths up to the age of 18 years (excluding stillbirths and lawful planned terminations)
  • collecting and collating information on each child from professionals and family
  • discussing each child’s case, and agreeing who will provide feedback to the family, in an appropriate and timely manner
  • establishing if there were any modifiable factors leading to the child’s death and decide what, if any, actions could be taken to prevent such deaths in future
  • making recommendations to the LSCP 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 LSCP
  • where a suspicion arises that neglect or abuse may have been a factor in the child’s death, referring a case back to the chair of the LSCP to consider whether a CSPR is required

The aggregated findings from all child deaths should inform local strategic planning, including the local joint strategic needs assessment, on how to best safeguard and promote the welfare of children in the area.

Timeline flow chart1