Initial Notification Form for Child Death

All Child Death notifications must be sent to the Single Point of Contact:

Tel: 020 8496 3691, Fax: 020 8496 6909

The security of any system used for transferring the information on these forms must be clarified and agreed with the Caldicott Guardian. All sections must be completed on the initial notification form. If written by hand, please complete in block capitals. Thank you.

Date of referral
Name of referrer
Agency
Address
Name of consultant Paediatrician/ Other Consultant
Email of referrer

Child Details

Full name of child / DOB / Sex
Alternative names / NHS No
Address of child
(Including postcode)
Name of persons with parental responsibility i.e. mother, father, or other (state relationship)
Ethnic group / c White British / c Black Caribbean / c Asian/ Indian
c Mixed White & Black African / c White Irish / c Black African / c Asian/ Pakistani
c Mixed White & Black Caribbean / c White Other / c Black Other / c Asian/ Bangladeshi
c Mixed White & Asian / c Chinese / c Mixed Other / c Not Known
Date of death / Time of Death
Place of death (*see note below)*
Follow-up appt to be arranged (Yes or No) / With whom?
Death certificate issued (Yes or No)
Any known cause(s) of death, as specified on the death certificate / Ia
Ib
Ic
II

* Place where the child is believed to have died, or where the event directly leading to death occurred.

Notification Details:

Please outline circumstances leading to the child’s death. Also, include if any other review is being undertaken and if any action is being taken as a result of this death. Please use the box below to give as much information as possible.


Other significant family and household members

Full Name / DOB / Relationship / Full Address (if different from child)

Contact details of agencies

Agency / Name, Address & Telephone Number
GP
Midwife/Health Visitor/School Nurse
Paediatrician
Police
Child’s social care
School/Nursery etc
Others (list all agencies known to be involved e.g obstetrician, community paediatrics)

Recording Details

Was this death expected or unexpected? I.e. not expected in previous 24hrs (Must be completed) / Expected c / Unexpected c
Reported to coroner (Yes or No) / If Yes please state name of coroner and number if known.
Post mortem examination (Yes or No)

2

Jan 2010