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Post mortem
Throughout this process, senior management should be kept informed of developments, and if at any point abuse or neglect is considered to have been a factor in the death then strategy meetings should be held in relation to any other children in the household and a referral made to the Islands Child Protection Committee for consideration of a serious case review.
The Law Officers have the power to order a post mortem. This will usually happen following the unexpected death of a child.
In order to assist the police/Law Officers in their investigation, all agencies must submit a report which includes a review of their social care records - this report must be submitted within 28 days of death.
Strategy meeting following preliminary results
Whilst the results of the post mortem are the property of the Law Officers, police, health professionals (i.e. paediatrician and pathologist) a strategy meeting should still be convened. This meeting should be convened and chaired by the responsible paediatrician.
The purpose of this is to:
- review any further information that has come to light
- determine whether there is any indication that abuse or neglect may have been the cause of, or contributed to, the death
- determine whether any safeguarding issues have been identified in relation to other children (however, all professionals should be advised to contact social care at any point during the investigation if it is suspected these children could be at risk).
It may be that it is still not possible to make such determinations at this stage, and that agencies must wait for the final results of the post-mortem.
Strategy meeting following final results
A strategy meeting should be held as soon as the final results are available. Such a meeting should include:
- those who knew the family
- those involved in investigating the death
The meeting should be convened and chaired by the responsible paediatrician. The purpose of the meeting is to:
- share information to identify the cause of death
- share information to identify any contributing factors to the death
- plan future care for the family
- identify any lessons that can be learnt
- inform the inquest
- explicitly discuss the possibility of abuse or neglect causing or contributing to the death - where no evidence is identified this should also be recorded
- decide how the family are to be informed of the final outcome.
A copy of the minutes of this meeting should be sent to the coroner, along with minutes of any previous meetings.