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ESCB Number
Agency Report Form B - For Neonatal deaths only
Please return the completed form by secure email to cdr@essex.gov.uk.cjsm.net
If your email is insecure, please send to cdr@essex.gov.uk password protected.
Alternatively you can fax it through on 01245 434715.
Telephone Contact: 03330 139172
The security of any system for transferring the information on these forms
must be clarified and agreed with the Caldicott guardian.
Please complete this form based on the information you have. If you are in any
doubt about what information to provide, please discuss with your manager.
Completing the form: The form is sent to all agencies involved with a
neonate/infant and family. Some information is collected in tick box or yes/no
format to allow collation and comparison of data, but in each section there is
space for more narrative/qualitative information which will help the
Neonate/infant Death Review Panel to more fully understand the nature of
each neonate/infant’s death. If you do not have information for any
particular section, please either circle NK (Not Known) or NA (Not
Applicable) this indicates to the CDR panel that you have considered the
question but have no information.
If this is the first time you have completed a Form B and you have any
queries, please do not hesitate to contact us.
All forms are available on our website http://www.escb.co.uk/
Purpose: Form B is designed to gather information about each
neonate/infant’s death. Its primary purpose is to enable the local CDR panel
to review all neonate/infantren’s deaths in their area in order to understand
patterns and factors contributing to neonate/infantren’s deaths and ultimately
to take steps to prevent future neonate/infant deaths.
Confidentiality: The information requested on this form will be used for the
purposes of neonate/infant death review as outlined in Chapter 5 of Working
Together to Safeguard Neonate/infantren March 2015. All bereaved parents
are informed of these processes. The nature of the information collected
means it is likely that some of the information is personal/sensitive data and
therefore CDR panels should be mindful of their obligations under the Data
Protection Act (DPA) 1998 when processing that information. All cases will be
anonymised prior to discussion by the CDR panel. All information gathered
will be stored securely and only anonymised data will be collated at a regional
or national level.
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A Identifying and Reporting Details
Name
DOB
NHS No.
Date of death
Address
Postcode
Agency Report Provided by
Organisation
Name
Job Title
Address
Postcode
Tel No
Email
Signature
Date:
B Summary of Case and Circumstances leading to the death
This section provides information on the nature and manner of the neonate/infant’s
death. Please complete any information which you hold on the case.
The ‘Details of the Death’ section is to be completed by the treating doctor
involved with the neonate/infant at the time of death – other professionals can
complete this section if they have the information.
Details of the death
What is your understanding
of the cause of death?
What was the mode of death?
Planned palliative care
Witholding, withdrawal or limitation of lifesustaining treatment
Brainstem death
Failed Cardiopulmonary resuscitation
Witnessed event
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Found dead
Not known
Has a medical certificate of the cause of death been
issued?
Yes
No
N/K
Was this death referred to the coroner?
Yes
No
N/K
N/A
Was a post-mortem examination carried out?
Date of PM if known
Place of PM if known
Yes
No
N/K
N/A
Has an inquest been held?
Yes
No
N/K
N/A
Date of inquest (if known)?
Verdict:
Registered cause of death if known
1a
1b
1c
II
(a)Main diseases or conditions in neonate/infant
(b)Other diseases or conditions affecting neonate/infant
(c)Main maternal diseases or conditions affecting neonate/infant
(d)Other maternal diseases or conditions affecting neonate/infant
(e)Other relevant conditions
All – please complete
Where is the neonate/infant
at the time of the event or
condition which led to the
death
Acute
Hospital
Emergency Dept
Paediatric Ward
Neonatal Unit
Paediatric Intensive Care Unit
Labour Ward
Other
Home of normal residence
Other private residence
Foster Home
Residential Care
Public place
Hospice
Abroad
Other
(specify)
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Not known
Where was the
neonate/infant when the
death was confirmed?
Acute
Hospital
Emergency Dept
Paediatric Ward
Neonatal Unit
Paediatric Intensive Care Unit
Labour Ward
Other
Home of normal residence
Other private residence
Foster Home
Residential Care
Public place
Hospice
Abroad
Other
(specify)
Not known
Were any of the following events known to have occurred?
Neonatal Death
Death of an neonate/infant with life limiting
condition (to be completed by the lead
clinician or designated member of the
palliative care team)
Complete B3
Sudden unexpected death in infancy (to be
Complete B4
completed by the SUDI paediatrician or
designated deputy, and will almost always be
completed at or immediately after the local
case review meeting. In those rare instances
in which there is no local case review meeting
the SUDI paediatrician or designated deputy
should complete this form at the conclusion of
the investigation)
Provide information via the MBRRACE-UK on
line reporting system
Date Sent
Send a copy of your MBRRACE-UK notification
to the Child Death Review Manager,
cdr@essex.gov.uk.cjsm.net
Date Sent
Send a copy of the Discharge Summary to the
Child Death Review Manager,
cdr@essex.gov.uk.cjsm.net
Date Sent
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Was the baby born in hospital?
Yes
No
Had the baby left hospital after birth?
Yes
No
Provide a narrative account of the circumstances leading to the death. This should
include a chronology of significant events in the background history, and details of
any important issues identified. Please also include antenatal information including
antenatal care, booking, appointments attended, circumstances around birth and
engagement with services.
Consider:
Events leading to death
Early family history
Pregnancy and birth
Neonatal period
C The Neonate/infant
This section provides information about the neonate/infant and any known conditions
or factors intrinsic to the neonate/infant that may have contributed to the death.
Please complete any information which you hold on the case.
Gender
Age at death
Male
/
/
(yy / mm / dd)
Indicate if estimated Age confirmed
Female
lbs
Birth weight
(gm or oz/lb)
oz
Last known height
kgs
cm
Age estimated
ft/in
Date
Last known
weight
Date
Ethnic
lbs
kgs
White
oz
Gestational age at
birth (completed
weeks)
English/Welsh/Scottish/Northern Irish/British
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group
Irish
Gypsy or Irish Traveller
Any other White background (please specify
)
Mixed/multiple
ethnic groups
White and Black Caribbean
White and Black African
White and Asian
Any other mixed/multiple ethnic background
(please specify
)
Asian or Asian
British
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
(please specify
Black/African/C
aribbean/Black
British
)
Caribbean
African
Any other Black/African/Caribbean
background
(please specify
Other ethnic
group
)
Arab
Any other ethnic group
Not known/not
stated
Religion
(please state)
Any known medical conditions at the time of death?
Yes
No
N/K
Yes
No
N/K
Yes
No
N/K
If yes, please provide details
Any known medical condition in utero for
mother/baby?
If yes, please provide details
Any known developmental impairment of disability at
the time of death?
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If yes, please provide details
Any medication at the time of death?
Yes
No
N/K
If yes, please provide details
Factors in the neonate/infant:
Provide a narrative description of any relevant factors within the neonate/infant that
have not already been covered. Include any known health needs; factors influencing
health; growth parameters; development issues; behavioural issues; social
attachment; any identified factors in the neonate/infant that may have contributed to
the death. Include strengths, as well as difficulties
D Family and Environment
This section provides details of the neonate/infant’s family and close environment.
Please complete with any information known to you.
Full Name
DOB
Relationship
Full Address
Mother
Age
Smoker
Occupation
Yes
No
Living in
primary
household
Any known:
Disability including
learning disability?
Yes
No
If yes please
provide details.
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Yes
No
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N/K
N/A
Yes
No
N/K
N/A
Yes
No
N/K
N/A
Yes
No
N/K
N/A
Known to police?
Include driving
offences
Yes
No
N/K
N/A
Any known health
problems during
pregnancy with
deceased
neonate/infant
Yes
No
N/K
N/A
Mental health
issues
Substance
misuse?
Alcohol misuse?
If yes please
provide details.
If yes please
provide details.
If yes please
provide details.
Please provide
details.
Please provide
details
Father
Age
Smoker
Occupation
Yes
No
Living in
primary
household
Any known:
Disability including
learning disability?
Yes
No
N/K
N/A
Yes
No
N/K
N/A
Yes
No
N/K
N/A
Yes
No
N/K
N/A
Known to police?
Include driving
offences
Yes
No
N/K
N/A
Any known health
Yes
No
Mental health
issues
Substance
misuse?
Alcohol misuse?
If yes please
provide details.
If yes please
provide details.
If yes please
provide details.
If yes please
provide details.
Please provide
details.
Please provide
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Yes
No
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problems during
pregnancy with
deceased
neonate/infant
details
N/K
N/A
Other Significant Adult
Age
Smoker
Occupation
Yes
No
N/K
N/A
Living in
primary
household
Relationship to
neonate/infant
Any known:
Disability including
learning disability?
Mental health
issues
Substance
misuse?
Alcohol misuse?
Known to police?
Yes
No
N/K
N/A
Yes
No
N/K
N/A
Yes
No
N/K
N/A
Yes
No
N/K
N/A
Yes
No
N/K
N/A
If yes please
provide details.
If yes please
provide details.
If yes please
provide details.
If yes please
provide details.
Please provide
details.
*If the neonate/infant is living in more than one household, for example where the parents have separated, the
primary household is where the neonate/infant spends most of his/her time; please provide any relevant details in the
narrative section.
Any known domestic violence
in the household?
Was the neonate/infant an
asylum seeker?
Yes
No
N/K
N/A
Yes
No
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Details
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Factors in the family and environment
Please provide a description of any relevant factors known to you that have not been
covered elsewhere.
Consider: family structure and functioning; wider family relationships; housing;
employment and income; social integration and support; community resources.
Include strengths and difficulties
E Parenting Capacity
The purpose of this section is to understand factors in relation to the care of the
neonate/infant that may have been of relevance in any way to the neonate/infant’s
death, and also factors that may have contributed to support and nurture of the
neonate/infant. Please complete any information known to you.
Where was the neonate/infant
Parental home
living at the time of their death or
Other relatives
the event leading to their death?
Foster carers
Private fostering
Residential unit
Long stay hospital
Hospice
Other
Who was directly looking after the
neonate/infant at the time of their
death or the event that led to their
death?
(please tick all that apply)
Mother
Father
Other adults (please list and give adults
relationships with the neonate/infant)
Health care staff
Others (please list below)
Was the neonate/infant subject to
a child protection plan?
Category of most recent child
protection plan:
At the time of death
Previously
Not at all
Physical abuse
Neglect
Emotional abuse
Sexual abuse
Not known
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Was the neonate/infant subject to
any statutory orders?
Category of most recent
statutory order:
At the time of death
Previously
Not at all
Police Powers of Protection
Emergency Protection Order
Interim Care Order
Care Order
Supervision Order
Residence Order
Section 20 (Neonate/infantren Act
1989)
Antisocial behaviour order
Other court order, please specify:
Had the neonate/infant been
assessed as a child in need under
section 17 of the Children Act?
At the time of death
Previously
Not at all
Were any siblings subject to a
child protection plan?
At the time of death
Previously
Not at all
Were any siblings subject to any
statutory orders?
At the time of death
Previously
Not at all
Are mother and
father related to
each other
(excluding
marriage)
Yes
No
N/K
N/A
Please provide
details.
Factors in the parenting capacity
Include family structure and functioning; wider family relationships; housing;
employment and income; social integration and support; community resources;
include strengths and difficulties.
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F Service Provision
The purpose of this section is to obtain a profile of the services being offered to the
neonate/infant and family; the effectiveness of those services in supporting the
neonate/infant and family; and to identify any unmet needs or gaps in services.
Please complete any information you are able to on your agency.
Details of agency involvement
Please indicate whether any of the services listed were involved with the
neonate/infant, or in neonatal deaths, with the mother. Where any service was
involved, please provide details in the narrative section below.
Include dates of first and most recent contact with family; services offered/provided.
Agency /
professional
Primary Health Care
Involved at the time of
death or in relation to the
final illness*
Yes
No
N/K
N/A
Details of involvement:
Secondary/Tertiary
Hospital Services
Yes
No
N/K
Yes
No
N/K
N/A
Yes
No
N/K
N/A
Yes
No
N/K
N/A
Yes
No
N/K
N/A
Yes
No
N/K
N/A
Yes
No
N/K
N/A
Yes
No
N/K
N/A
Details of involvement:
N/A
Details of involvement:
Local Authority
Children’s Services
N/K
Details of involvement:
Details of involvement:
Police
No
Details of involvement:
Details of involvement:
Hospice Services
Yes
Details of involvement:
Details of involvement:
Secondary/Tertiary
Community Health
Services
Involved previously
Yes
No
N/K
N/A
Details of involvement:
N/A
Details of involvement:
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Yes
No
N/K
Details of involvement:
N/A
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Agency /
professional
Probation
Involved at the time of
death or in relation to the
final illness*
Yes
No
N/K
N/A
Details of involvement:
Other – specify
Yes
No
N/K
Involved previously
Yes
No
N/K
N/A
Details of involvement:
N/A
Details of involvement:
Yes
No
N/K
N/A
Details of involvement:
*Include all those providing services at the time of death or in relation to the final illness, even if not present at the
time of the death; e.g. neonate/infant on school roll; planned out patient follow up; active social work case; palliative
care.
If no professionals involved, what was the
last known contact of a professional from
your agency?
Professional
Date of last known contact
/
/
No known contact from this agency
Not known
Were there any identified unmet
needs/gaps in services? (if yes, please
provide details below)
Yes
No
N/K
N/A
Were there any identified difficulties in
family engagement with services? ( if yes,
please provide details below)
Yes
No
N/K
N/A
Factors in relation to service provision
Please complete any information known to you in relation to service provision that
has not been covered elsewhere.
Consider any identified services both required and provided; the nature and timing of
any services provided; any gaps between neonate/infant’s or family member’s needs
and service provision; any issues in relation to service provision or uptake,
positive/negative in relation to bereavement care.
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Was there a formal Critical Incident
investigation – if yes, please state which
specific agency
Yes
No
Any other internal agency investigation (please specify
)
Is this neonate/infant death the subject of a
serious case review
No
Yes
N/K
N/A
N/K
N/A
Issues for discussion
Include any action or learning to be taken as a result of the neonate/infant’s death;
issues that require broader multi-agency discussion
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