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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

   /    /     

     days/months/years



NHS No.      

Address

     

Postcode

     

School/nursery etc

     

Date & time of death

   /    /      Time      

Other significant family members

         


Referral details


Date of referral

   /    /     

Name of referrer

     

Agency

     

Address

     

Tel Number

     

Email

     


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?



Expected



Unexpected

Reported to Coroner




Y / N / NK /NA

   


Date:    /    /     










Name:      

Reported to Registrar




Y / N / NK /NA

   


Date:    /    /     










Name:      

Has a medical certificate of cause of death been issued?




Y / N / NK /NA

   


Date:    /    /     

Post mortem examination:




Y / N / NK /NA

   


Date:    /    /     










Venue:      

† 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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