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Form a notification of Child Death

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Form A - Notification of Child Death

CDOP Identifier (Unique identifying number) ………………………………………….

Form A - Notification of Child Death

Notification to be reported to CDOP Manager at: Email:           

Tel:       Fax:      

The information on these forms and the security for transferring it to the CDOP Co-ordinator should be clarified and agreed with your local Caldicott guardian.

If there are a number of agencies involved, liaison should take place to agree which agency will submit the Notification.

Child’s Details

Full Name of Child


Any aliases



DOB / Age

   /    /     


NHS No.      





School/nursery etc


Date & time of death

   /    /      Time      

Other significant family members


Referral details

Date of referral

   /    /     

Name of referrer






Tel Number




N.B. Page 1 can be removed for the purposes of anonymising the case. Page 2 should be made available with Form B to the child death overview panel.

Details of the death:

Location of death or fatal event

(Give address if different from above)


Death expected?



Reported to Coroner

Y / N / NK /NA


Date:    /    /     


Reported to Registrar

Y / N / NK /NA


Date:    /    /     


Has a medical certificate of cause of death been issued?

Y / N / NK /NA


Date:    /    /     

Post mortem examination:

Y / N / NK /NA


Date:    /    /     


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

Notification Details:

Please outline circumstances leading to notification. Also include if any other review is being undertaken e.g. internal agency review; any action being taken as a result of this death.


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