STRICTLY CONFIDENTIAL

Child Death Notification Dataset

Barnet

Initial notification of the death of a child – to be completed as fully as possible within 24 hours.

DO NOT DELAY

Please return completed form to

Initial notification Unique Reference Number
To be completed by Child Death Review Co-ordinator / SX// /
Family Name of Child / First and Other Names of Child
Date of Birth of Child / Sex of Child (Male/Female) / SelectFemaleMale
Date of Death (DD/MM/YYYY) / Time of Death (HH:MM)
Ethnicity of the Child / SelectWhite: BritishWhite: IrishWhite: Any Other White backgroundWhite: Traveller of Irish HeritageWhite: Gypsy/RomaMixed: White & Black CaribbeanMixed: White & Black AfricanMixed: White & AsianMixed: Any other mixedAsian or Asian British: PakistaniAsian or Asian British: BangladeshiAsian or Asian British: Any other AsianBlack or Black British: CaribbeanBlack or Black British: AfricanBlack or Black British: Any other black backgroundChineseAny other (Please specify)Not known / Not Stated
If ‘Other’, please specify
Carer of Child at time of Death
Name/s of persons with parental responsibility i.e. mother, father or other (state relationship)
Name / DOB / Sex
(Male/Female) / Address
(if different from home address): / Relationship to Child
(e.g mother, father)
SelectFemaleMale / N/A
SelectFemaleMale / N/A
Home Address of Child / Postcode
GPs name, address and telephone number
Other children in household or affected by the death (including children potentially at risk of harm)
Please use the box at the end of the form if additional space is needed
Name / DOB or Age (if known): / Sex (Male/Female)
SelectFemaleMale
SelectFemaleMale
SelectFemaleMale
Location of death or fatal event [1] / l / Contact Number
Senior medical practitioner present at time of death / Contact Number
Is this an unexpected death?
i.e. not expected in the previous 24 hours / SelectExpectedUnexpected - Important Information
Has this been confirmed by the designated doctor for child death? / SelectYesNo
Is a post-mortem required? / SelectYesNo
Summary Description of the Circumstances of the Death
Print Name / Organisation
Signature
Date of Notification (DD/MM/YYYY) / Time of Notification (HH:MM)

Confidential Feb 2010

[1] place where the child is believed to have died, or where the event directly leading to death occurred. For example, if a child is involved in a road traffic accident, and is resuscitated but subsequently dies, the location of death should be recorded as the site of the collision, rather than the hospital where the child's death was confirmed