Review of child deaths and non-accidental injuries in children

The general purposes of a death investigation are to eliminate the risk of undetected homicide or other crime; to identify preventable dangers to life and to the health and safety of the public; to allay public anxiety; to restore public confidence; to assist in the maintenance of accurate statistics and to secure and preserve evidence.

The system for the investigation of death - which includes both the Crown’s investigative functions and the availability, in certain circumstances, of a Fatal Accident Inquiry - gives effect in Scotland to the United Kingdom’s obligations under Article 2 of the European Convention on Human Rights - right to life. In the case of any death to which Article 2 applies, the whole investigation must comply with the requirements of Article 2.

The purpose of the Crown Office and Procurator Fiscal Service (COPFS) is to secure justice for the people of Scotland in respect of the investigation and prosecution of crime and also conduct the investigation of deaths. COPFS aims to investigate thoroughly, robustly and timeously all sudden, unexplained, or suspicious deaths whilst keeping bereaved relatives updated during our investigations. COPFS is committed to modernising the way we work securing efficient and effective justice and putting the public interest at the heart of all we do.

COPFS also has a responsibility to consider patterns or spikes in all deaths and when such a pattern emerges to investigate accordingly. Equally, COPFS aims to take action to raise awareness of and to reduce preventable deaths.

The loss or serious injury of a child is the worst experience that any family is likely to endure. From 1 January to 31 December 2023, 157 child deaths were reported to COPFS.

The Review of Child Deaths and Non-Accidental Injuries in Children (henceforth the ‘Review’), was instructed by the Solicitor General for Scotland in light of the publication of the Healthcare Improvement Scotland report in relation to child deaths, the introduction of reviews for all child deaths in Scotland, the inception of the United Nations Convention on the Rights of the Child (UNCRC), and also taking into account the lived experiences of families who have lost a child.

It is of note that the Healthcare Improvement Scotland report determined that Scotland has a higher mortality rate for under-18s that most other Western European countries – with around 300 children and young people dying every year. It is thought that around a quarter of those deaths could be prevented.

The child, and their family, were at the core of this Review which aimed to balance the need to treat families, victims and witnesses with dignity and compassion by providing them with the respect, professionalism and service they deserve from COPFS as the sole prosecution and deaths investigation authority in Scotland whilst ensuring that such cases are thoroughly, diligently and expertly investigated, prepared and prosecuted.

It is intended that the recommendations arising from this Review will build upon the
good work already carried out in this area and provide a relevant, modern and trauma-informed framework upon which to continue to develop and improve our work in these most sensitive and challenging of cases. It is also hoped that the review will act as a starting point for further significant conversations and work as recommended.

Prevention of child deaths in Scotland, along with identifying learning and training for COPFS staff, were central to the purpose this Review. The Terms of Reference were as follows:

To review the investigation, prosecution and presentation of cases involving child death or serious injury and report with recommendations to the Solicitor General for Scotland. To cover the following areas:

• The guidance to prosecutors for the investigation and prosecution of child deaths, and cases involving serious injury of a child.
• The guidance to police for the investigation and prosecution of child deaths, and cases involving serious injury of a child.
• The requirement for Lord Advocate’s guidelines, in relation to child deaths and
  cases involving serious injury of a child.
• The training available for police and prosecutors in relation to child death and serious injury. Whether there should be joint training, or elements of joint training, and whether accreditation is necessary.
• Where cases involving serious injury of a child should be investigated, and the
  elements required for such an investigation.
• The availability of expertise to police and prosecutors, and in particular medical/pathology expertise and what can be done to improve that position.
• Review of recent Fatal Accident inquiries involving child deaths.
• Whether there should be further involvement of the COPFS Health and Safety Investigations Unit in child death cases.
• How COPFS review and debrief cases of child death and serious injury.
• The implications of UNCRC for these cases.

The Review afforded an opportunity to learn from current processes and practices and to determine how and where COPFS can improve in this important, challenging and sensitive area of work.

It is vitally important that this Review generates both the necessary platform and momentum to bring about positive, practical and meaningful change both for families and practitioners.

To that end, during the Review these themes emerged:

1. Reduction of journey times in child death cases – it is acknowledged that sometimes a child death investigation can take a considerable time and, in some instances, longer than the child’s short life which is undoubtedly hugely traumatic for families.
2. Ensuring best practices and the need to capture learning and improve training in how to sensitively and professionally deal with these cases – this is reflected in the need for a de-brief process and enhanced structured training for COPFS staff, pathologists and Police Scotland officers.
3. It is now time to establish permanent change and greater consistency of approach. A modern structure to facilitate that change can be introduced through the creation of Lord Advocate’s Guidelines on child deaths/ nonaccidental
   injuries in children, and by establishing a COPFS Child Death and Non-Accidental Injuries Improvement Board (the ‘Improvement Board’).
4. Explaining the role of the Procurator Fiscal in death investigations and criminal investigations and what families can expect from COPFS when a child dies by enhancing our external website and promoting our work publicly. De-mystification of the role of the Procurator Fiscal could provide reassurance and build trust for bereaved families.
5. Taking a trauma-informed approach is important in how COPFS staff interact with families, victims and witnesses, taking account of lived experience. It also relates to COPFS staff, recognising the impact that dealing with these cases has on them. Vicarious trauma counselling and a COPFS Internal Network for staff who deal with child deaths/ non-accidental injuries are important to ensure that our people are as well equipped as they can be to deal with such cases.
6. Collaborative working is key to continuous learning and sustained improvements to make a tangible difference in child deaths. Whilst COPFS is the sole deaths investigation authority in Scotland, there is a collective responsibility across society to reduce and prevent child deaths wherever possible. To that end, future working with stakeholders is fundamental to making meaningful, practical change which is reflected in the need for multi-agency workstreams to address ongoing issues and challenges as part of the Improvement Board.

1. That there should be a time-limited Scottish Fatalities Investigation Unit (SFIU) team established to specifically target child/baby deaths for a set period with the aim of reducing journey times in these cases. Thereafter, the necessary additional resource deployed to the team would be retained by SFIU to absorb the work across the unit to reduce overall journey times consistently going forward.
2. That there ought to be an agreed process for police to report non-accidental injury cases to COPFS
3. That the database of experts set up by SFIU should be promoted more widely and become more readily available for others across COPFS to access and contribute to.
4. There should be a de-brief process for all cases of child death/ serious injury dealt with by COPFS by way of a ‘child deaths/ serious injury learning outcomes’ meeting.
5. That Lord Advocate’s guidelines are produced in relation to child deaths and non-accidental injury cases to provide a framework of clarity and consistency both for Police Scotland and COPFS staff when dealing with these cases.
6. All COPFS staff undertaking child deaths work should continue to complete the mandatory training and e-learning on UNCRC and that the UNCRC leads for Homicide/ SFIU will continue to consider UNCRC implications across all cases which will be recorded.
7. That information about the death investigation system on the COPFS external website should be enhanced. This should include improving the guide to bereaved relatives about the process with short video clips - such footage
   should reflect the need to balance the integrity of a scene/ investigation and
   treating families with compassion and dignity.
8. It is recommended that the section on the COPFS website that deals with child deaths and non-accidental injuries in children also has an associated ‘frequently asked questions’ section for parents/ carers to refer to. This section should also include links and signposting to support agencies.
9. It is recommended that Police Scotland and COPFS work together jointly to identify gaps in knowledge and training and to facilitate joint training as necessary.
10. That an Improvement Board should be established to implement the recommendations of this Review and to consider learning from the Kennedy principles which form the basis of child deaths investigations in England and Wales and how it could apply in Scotland.
11. That COPFS should help to facilitate joint scenario training for Police Scotland, COPFS and medical professionals, enabling practitioners to learn in a safe environment.
12. That COPFS should continue to work collaboratively with Police Scotland and
    the National Crime Agency to maximise information sharing and learning including by holding awareness sessions on a regular basis.
13. That, as part of the work of the proposed Improvement Board a multidisciplinary
    work stream should be established made up of representatives from the Scottish Health boards, Police Scotland, Scottish Ambulance Service, paediatric pathologists, paediatricians and Healthcare Improvement Scotland.
14. That there should be an annual review of child deaths by COPFS and the paediatric pathologists who undertake COPFS work. The review will focus on the number of child deaths and seek to identify any trends, peaks or patterns in deaths reported to COPFS which would benefit from increased public awareness in order to prevent future deaths.
15. COPFS will continue to provide training for pathologists to improve their learning and understanding of the role of COPFS.
16. There should be mandatory training for all COPFS practitioners carrying out this work – attendance at the annual training day on child deaths/nonaccidental injuries in children along with a case preparation course, a course on how to communicate with next of kin, victims and witnesses and additional advocacy training.
17. The training should be undertaken within three months of moving to a team which carries out this case preparation work. For court practitioners attendance at the relevant advocacy course should be recorded as a professional development objective.
18. Vicarious Trauma assessments should be bespoke and in-person for those dealing with these cases. They should take place annually as standard but potentially every six months depending on individual caseloads.
19. That the recently established COPFS Children’s Network for all practitioners
    involved in this work should meet quarterly to share learning, raise awareness of these cases and provide further support for those involved in this work.

In light of the volume of recommendations work has begun to establish the COPFS Child Death and Serious Injuries Improvement Board to progress and implement the recommendations of this Review as agreed by the Solicitor General.

The Board will be chaired by a senior member of COPFS staff with membership made up of COPFS staff across all grades and functions. One of the first considerations of the Board will be how to involve key stakeholders including next of kin.

In developing the Board we will address two of our key priorities as set out in the COPFS Strategic Review 2023-27:

• Improve how we communicate with our customers and partners and the support we offer to the most vulnerable service users.
• Achieve quicker conclusions to criminal and death investigations

The early establishment of the Board would maintain the momentum created by this Review which has been my pleasure and privilege to lead.

Deborah O’Brien Demick
Assistant Procurator Fiscal
November 2024