Each death of a child is a tragedy for his or her family, and subsequent enquiries / investigations should keep an appropriate balance between forensic and medical requirements and the family’s need for support. A minority of unexpected deaths are the consequence of abuse or neglect or are found to have abuse or neglect as an associated factor. Across Dudley, all statutory agencies are committed to working together to conduct coordinated enquiries.

Government legislation since April 2008 require LSCB’s to review the death of every child (from 0 up to the age of 18) in the area. This reflects the need to learn any lessons that may help to reduce child deaths in the future.

Child Death Review Sub-Group

The Child Death Review Sub-Group meets bi-monthly and all child deaths are reviewed and it is responsible for collecting and analysing information about the death of every child under 18 years in Dudley with a view to:

  • Identifying any matters of concern affecting the safety & welfare of children in the area
  • Identifying any wider public health or safety concerns arising from a particular death or pattern of deaths the area
  • Identifying any case that should be considered as a Serious Case Review

It also has the job of overseeing the process of conducting a rapid response by a group of key professionals to enquire into and evaluate each unexpected death of a child.

Unexpected Deaths – Rapid Response Procedure

An unexpected death is defined as the death of an infant or child which was not anticipated as a significant possibility i.e. 24 hours before the death or where there was a similarly unexpected collapse leading to or precipitating the events which led to the death.

Whenever an unexpected death of a child occurs, a multi-agency response is initiated including a lead Consultant Paediatrician, a West Midlands Police Senior Investigating Officer, A & E staff, ambulance staff, GPs, social care, health visitors and the Coroner to enquire into the circumstances of the death, determine who will support the family and ensure there are no safeguarding concerns for other children in the family.

A decision will be made as to which professional will take the lead. This would be the police where there are apparent suspicious circumstances or other external factors. The lead Paediatrician would usually take the lead where there are apparent health or medical factors which have resulted in the death of the child.

Modifiable Factors

The Panel will consider whether there were any modifiable factors identified during the review of the death which may have contributed to the death of the child and which, by means of locally or nationally achievable interventions, could be modified to reduce the risk of future child deaths. These modifiable factors will help inform the public health agenda and inform staff of the emerging themes arising from the review of child deaths.