Children pronounced life extinct pre-hospital guideline

The Child Death National Review Processes have identified that a for number of children pronounced life extinct pre-hospital with no apparent cause of death assessment by a paediatrician is helpful to:

• Understand the history leading up to the death, including identifying pertinent medical information which may inform the post-mortem
• Examine the body to look for signs of underlying cause of death including signs of injury
• Allow discussion with the family and carers which may help them to understand what has happened and what will happen next.

Whilst paediatricians are accustomed to this process when resuscitation has been ongoing on arrival to hospital or in the event of a SUDI, recent changes in multiagency process across Scotland have led to this process applying to all sudden deaths in children under 18 years of age, even when resuscitation is deemed futile.

This purpose of this process is not to

• Exclude foul play
• Identify cause of death
• But does often provide further information to support the Police in briefing the Procurator Fiscal for decision making around post-mortem, child protection procedures for surviving siblings and management of the parents/adults associated with the deceased child.

This document aims to highlight in brief key steps in the process from notification of a child death acknowledging that all circumstances will be unique.

It should be noted that all sudden and unexpected deaths in children are notified to the Procurator Fiscal and therefore healthcare staff are working with and under the guidance of Police Scotland.

SUDICA can be one of the most difficult experiences than an ambulance crew will encounter. Please ensure that you are familiar with the current UKASCP Guidelines, 2016 (pp. 32-34). 

SUDICA pathway for ambulance crew.

Children where the death is anticipated or there is an anticipatory care plan in place will not be conveyed to hospital unless the death was not expected at that time.

If there are concerns criminality may be involved the child will not be conveyed to hospital.

Tayside pathway diagram.

Ideally this should be done with Police Investigating Officer to prevent the family needing to repeat any of the information they are providing.

• Events immediately leading up to death including details of any trauma (as you would usually ask when establishing mechanism of injury). If a child has died in their sleep a history of that sleep should be taken (see advice on SUDI website). In the event of what appears to be a deterioration in an established medical condition take details of how this evolved, medications given, doses and timings.
• Any previous medical illnesses, medications and if known to the paediatric team.
• Family history: particularly of any relevant factors including for example history of sudden death, cardiac disease in the young, miscarriages, metabolic history if thought to be of relevance.
• Social History –siblings and parent’s names, DOB, addresses and contact numbers. School or nursery attended and name of key staff. Any other agencies involved.

• The child/young person will require a top to toe examination.This should be done in the presence of the Police Scotland officer
• British Transport Police officers are also trained child death SIOs – whilst a top to toe is unlikely to be required for most BTP incidents there might be a requirement for incidents not involving trains.
• There may be a need for police photographs to be taken by the scene examiner and consideration should be given as to whether they should be present at the start of the top to toe (may be delayed and family may wish to know findings).
• Any positive findings should be recorded on a body chart (in addition to photographs as above).
• It is important to document the history given for any injuries found and who the history was taken from.

Whilst your primary instinct will be to provide care and support to the child and family it is important to remember that there is an ongoing police investigation. It is therefore important to liaise with the investigating officer and agree the following:

• If any clothes removed need kept or whether these can be returned to family (if they wish).
• The nappy, if present, should be removed and placed in an evidence bag (follow chain of evidence). A clean nappy can be put on (document this).
• Discuss if invasive medical equipment can be removed (for example ET tubes, intra-osseous needles, cannulae etc). If removed there should be clear documentation of what had been placed where (eg ET tube size x inserted to x cm, removed, green cannula inserted left antecubital fossa removed. It may be helpful to document on body chart).
• No samples should be taken from the body after death (eg no swabs, blood etc these will be undertaken at post-mortem if necessary).
• Police consent should be sought before asking the family if they wish mementos and keepsakes, for example hand prints or locks of hair. Again, ensure, if taken, these are documented clearly eg small sample of hair cut from left temple, handprints taken with blue ink, removed from feet. If Police have concerns they may instruct not to take these at the time but the family should be advised that mementos can also be taken at post-mortem and subsequently given to the family by the Police Family Liaison Officer.

Identifying the body –will be done by family with police and requires chain of evidence until child is transferred to the mortuary and to the post-mortem. The body will usually be transferred to Ninewells Hospital Mortuary but on occasion Bell Street Mortuary by Police Scotland.

• Standard hospital paperwork will be required to be completed to lodge the body in the mortuary (even if transiting).
• Additional Police Scotland paperwork may be required and will be completed by the investigating officer.

Each family will respond differently in this situation. Many will wish to spend time with their child, this should be discussed with the investigating officer and is usually acceptable but contact will need to be supervised at all times either by hospital staff or police. Depending on the circumstances of the death, the contact might be restrictive such as hand holding only for example. The paediatric team should provide support as needed and personalised to each family. It is important to avoid making promises or giving assurance to families about what will or won’t happen as this is a Police process. This can make families feel as if they are to blame or are under suspicion even when this is not the case. You may wish to offer:

• Extended family support/visiting in ED.
• Spiritual care –either family’sown support or via Hospital Spiritual Care Department.
• There will be a police family liaison officer allocated.
• Where possible, continuity of healthcare staff.
• Families need time.
• Careful considerations should be given as to the appropriateness of transferring the body to Ward 29 –it should be borne in mind that this area is full of noisy, active, alive children and crying babies. For some families who are well known to the ward this may be appropriate and of their choice. This decision requires support from Police Scotland and should be discussed between health and Police prior to being offered to the family. You should give consideration as to how you transfer the body through the hospital without causing distress to the family or the public.

• Ensure Health Visitor, School Nurse and GP are informed as appropriate. Complete NHS Tayside checklist on notifications.
• Ensure that there are contact details for the Lead Police Officer documented in the medical notes and that they also know how to contact the Paediatrician.
• Discuss with the family how they wish you to contact them and when. (Usually in the days following the death, with post mortem results and a few weeks afterwards) When the family leave the hospital ensure you have given them contact details for your secretary in case of any queries and ensure you have active mobile numbers. (Police may keep parent’s phones, so ensure you have additional contacts or Police Family Liaison Officer updates you with contact numbers).

For all children who die suddenly in childhood there will be an IRD held for the surviving children to ensure

1. safety and welfare
2. wellbeing and support.

The paediatrician should try to attend this or liaise with the Child Protection On Call Consultant/ NACP if needed.

• A fiscal post-mortem will be undertaken in all cases of sudden death.
• This will be a Police Post Mortem and you do not need signed consent (fiscal led). It is usually the Police who discuss this with the family but it may be the Consultant Paediatrician is asked about this and should inform the family of the process including that the child will be transferred to another hospital for the skeletal survey and postmortem, this is usually Aberdeen or Glasgow. It is also important to discuss neuropathology and retention of samples. If relevant the family should be made aware that sometimes the initial post-mortem does not identify a cause of death and they may not have the final post mortem report for many months. The family should be given the police leaflet on post-mortem.
• Any history you have established will be relevant to the post-mortem. At times there may be medical information that is key to the post-mortem findings. If you believe it would be of relevance to discuss directly with the pathologist you can obtain consent from the procurator fiscal to do so.
• It is very important that there is an agreement as to whom is communicating the post-mortem results. This is usually the Police in a fiscal post-mortem but if the cause of death is medical it can be of benefit that this is communicated by the Paediatrician. This is also the case if a diagnosis is made which has implications for other family members. A discussion should be had between the police, fiscal, pathologist and paediatrician as to who is best to communicate the results and when this will happen.

A red datix should be submitted on the day of the death recorded as unexpected child death and sent to the clinical care group manager for verification. The clinician involved is expected to lead the health element of the child death review and will be invited to the multi-agency review. An email should be sent to the Child Death Review Lead and this will initiate the process leading to the health review and subsequently Child Death Review. 

SUDI Scotland

RCPCH (2016). Sudden unexpected death in infancy and childhood: multi-agency guidelines for care and investigation.