Initial stages

When a child dies unexpectedly, Children's Services may not necessarily be the agency to be the first know. However, once notified, regardless of the status of whether the child is in care or not, there are processes that need to be followed. The process on this page should be completed by the end of the same working day as Children's Services being notified.

Unexpected death

Working Together 2013 defines an unexpected death as:

the death of an infant or child (less than 18 years old) which was not anticipated as a significant possibility for example, 24 hours before the death; or where there was a similarly unexpected collapse or incident leading to or precipitating the events which led to the death.

Child Death Review Process

When a child dies unexpectedly there is a requirement on the medical staff who confirm the death to follow the Child Death Review Process which is an Islands Child Protection Committee muliti agency protocol:

put in link:


The Child Death Review process details the involvement of primarily health and police staff, but also requires that Social Care are informed of the death.

The Child Death Review process is designed to establish quickly but sympathetically the circumstances of the death, as well coming to an early view as to whether abuse or neglect may have been a factor.  This process will however mean that a lot of information around the death should be available to Social Care very quickly.

First contact with Social Care

If you are the first person to be told about the death of a child then as much information as possible should be gathered:




This information will help to determine what action needs to happen next.

Once notified that a child has died, the Social Care database should be checked. If the child is known to Social Care then you should notify your line manager and Assistant Director immediately.

Please remember that the death of a child is a distressing event and staff working with the child should be informed sensitively and in a planned way. The managers must consider what help staff, as well as families, need at this point and throughout the process, for example access to the counselling service.

Responsibilities of the Director

Where the child is open to Social Care and initial indications are that there are concerning circumstances or the child is looked after, the l Director should:



  • inform the assistant director
  • ensure that the Lead Member for Children's Services is informed
  • ensure that a doctor has certified the death
  • determine with relevant professionals whether there will be a post mortem
  • determine whether there will be an inquest and if so inform Legal Services
  • in conjunction with senior management ensure HSSD Board Members are notified
  • ensure all case records are secured immediately

If the child is open to Social Care but there are no initial indications of concerning circumstances and the child is not looked after, then the  Director should ensure that the Assistant Director is informed and that if there is a post-mortem then the process set out to discuss the findings of the post-mortem are followed.

Strategy Discussion / Meeting

If there are other children in the household and initial indications are that there are concerning circumstances around the death then a strategy meeting should be held to plan how to keep the other children in the home safe.

This meeting should:

Follow the strategy meeting procedure.

Notifying external agencies

In the event of the unexpected death of a child open to social care, or where abuse or neglect is suspected, the HSSD Board Members should be advised by the using the form attached. If there is, or is likely to be, significant media attention linked to the death and / or subsequent inquest then the HSSD Board Members will need advice in order to form an  Incidents Briefing Team.

Summary of actions:



Person responsible



Obtain information about circumstances leading up to the death

Social worker (or duty worker if applicable)



Inform line manager and  Director

Social worker



Check to see if child known to Social Care and, if case closed what previous involvement was

Social worker / line manager



If no concerning circumstances identified around death and child not looked after then inform assistant director



Where concerning circumstances around death inform Director of Children's Services and Lead Member for Children's Services




Paper files to be placed in a locked place with access restricted. It may be necessary to restrict access to the electronic record if a crime has been committed

Divisional Director



Ensure that death has been certified by a doctor


By end of same working day


Determine whether there will be a post-mortem and inquest (informing Legal Services if there is to be an inquest)


By end of same working day


Inform Ofsted


By end of same working day


Strategy meeting to be held if concerns about abuse or neglect contributing to death and other children in household

Social worker / line manager

By end of same working day


Needs of staff to be considered (e.g. do they need extra support around specific aspects or around the impact on them?).

Consider whether HSSD Occupational Health have a role to provide counselling/debriefing.


Assistant Director

Line Managers