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9.1 Child Death Overview Panel


Caption: contents table
  Overall Principles
  The Regulations Relating to Child Deaths
  Definition of an Unexpected Death of a Child
  Children with Life-Limiting / Life-Threatening Conditions (LL/LT)
  CSAP Responsibilities for the Child Death Review Processes
  Other Related Processes
  Involvement of Parents/Family Members (for all Child Deaths)
  Responding to the Unexpected Death of a Child
  Reviewing Deaths of all Children
  Functions of the Child Death Overview Panel
  Duties of the CDOP Chair and Coordinator
  Taking action to Prevent Deaths
  Data Collection
  Working with the Media


  1. This chapter sets out the procedures to be followed - when a child dies in the area covered by the Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership (CSAP). There are two interrelated processes for reviewing child deaths (either of which can trigger a Child Safeguarding Practice Reviews):
    • A rapid response by a group of key professionals who come together for the purpose of enquiring into and evaluating each unexpected death of a child; and
    • An overview of all child deaths (under 18 years) in the Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership (CSAP) area undertaken by the Child Death Overview Panel (CDOP).
  1. For the purposes of the Lancashire and Blackburn with Darwen CDOP, the role referred to in Working Together to Safeguard Children as 'Designated Paediatrician for Unexpected Deaths', is taken by the Lead/Specialist Nurse for Sudden and Unexpected Deaths in Childhood (SUDC Nurse).

Overall Principles

  1. Each death of a child is a tragedy for his or her family, and subsequent enquiries / investigations should keep an appropriate balance between forensic and medical requirements and the family's need for support. A minority of unexpected deaths are the consequence of abuse or neglect, or are found to have abuse or neglect as an associated factor. In all cases, enquiries should seek to understand the reasons for the child's death, address the possible needs of other children in the household, the needs of all family members, and also consider any lessons to be learnt about how best to Safeguard and Promote Children's Welfare in the future.
  2. Families should be treated with sensitivity, discretion and respect at all times, and professionals should approach their enquiries with a critical appraisal.

The Regulations Relating to Child Deaths

  1. Two of the functions of the CSAP, in relation to the deaths of any children, normally resident in the area, are as follows:
    • To collect and analyse information about each death with a view to identifying:
      • Any case giving rise to the need for a Serious Case Review;
      • Any matters of concern affecting the safety and welfare of children within the area covered by the Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership (CSAP) areas;
      • Any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area, and
    • To put in place procedures for ensuring that there is a coordinated response by the Local Authority, their CSAP partners and other relevant persons to an unexpected death.

Definition of an Unexpected Death of a Child

  1. In this guidance an unexpected death is defined as the death of an infant or child (less than 18 years old) which:
    • Was not anticipated as a significant possibility for example, 24 hours before the death; or
    • Where there was a similarly unexpected collapse or incident leading to or precipitating the events which led to the death.
  2. For the deaths of pre-term infants please see additional definitions included in The Management of Sudden Unexpected Deaths in Childhood (SUDC);
  3. The SUDC Nurse should be consulted where professionals are uncertain about whether the death is unexpected. If in doubt, the processes for unexpected child deaths should be followed until the available evidence enables a different decision to be made.

Children with Life-Limiting / Life-Threatening Conditions (LL/LT)

  1. Children with a known disability or a medical condition should be responded to in the same manner as other children.
  2. It is expected that children with LL/LT conditions will die prematurely young, it is not easy to anticipate when, or in what manner they will die. Professionals responding to the death of a child with an LL/LT condition should ensure that their response to these families is appropriate, supportive and does not cause any unnecessary distress.
  3. The unexpected death of a child with LL/LT conditions should be managed as for any other unexpected death so as to determine the cause of death and any contributory factors.

CSAP Responsibilities for the Child Death Review Processes

  1. A sub-committee of the CSAP, the CDOP, is responsible for reviewing information on all child deaths. The disclosure of information about a deceased child is necessary to enable the CSAP to carry out its statutory functions relating to child deaths. The CSAP should use the aggregated findings from all child deaths, collected according to a nationally agreed minimum data set, to inform local strategic planning on how best to safeguard and promote the welfare of the children in their area.
  2. In each partner agency of the CSAP, a senior person with relevant expertise should be identified as having responsibility for advising on the implementation of the local procedures on responding to child deaths within their agency. Each agency should expect to be involved in a child death review at some time.

Other Related Processes

  1. Where there is an ongoing criminal investigation, the Crown Prosecution Service must be consulted as to what it is appropriate for the professionals to be doing, and what actions to take in order not to prejudice any criminal proceeding.
  2. Where a child dies unexpectedly, all NHS Trusts, should follow their locally agreed procedures for reporting and handling serious patient safety incidents.
  3. If it is thought, at any time, that the criteria for a Serious Case Review might apply, the Chair of the CSAP should be contacted and the Child Safeguarding Practice Reviews should be followed. For Blackpool children, see also Child Death Review Flowchart - Blackpool SCR / CDOP interface.

Involvement of Parents/Family Members (for all Child Deaths)

  1. The CSAP should inform parents and family members of the child death overview and rapid response processes using the nationally agreed "The Child Death Review" leaflet. This is delivered by the SUDC nurses on their visits with the family, or by the Registrar as the death is registered. The leaflet contains information on how to contact the CDOP Coordinator if you have further questions.

  2. Parents and family members should be informed that the objective is to "learn lessons in order to improve the health, safety and well-being of children and ultimately to prevent further such child deaths". Information which is to be shared with parents and family members should be agreed by the CDOP and a professional known to the family should deliver this information in a timely manner. Decisions on information sharing should be recorded in each agency's records.
  3. It is not appropriate for parents or family members to attend the CDOP as this is a meeting for professionals to discuss both individual cases and wider public health issues. Parents should be encouraged to contribute any comments or questions. Parents should be informed that case discussions are anonymous, information is stored securely and only anonymised data is collated regionally / nationally.
  4. CDOPs should ensure that whenever necessary, arrangements are made for the family to have the opportunity to meet with relevant professionals to help answer their questions, for example a professional known to the family before their child died, a paediatrician or Police officer.

Responding to the Unexpected Death of a Child

For more information see The Management of Sudden Unexpected Deaths in Childhood (SUDC).

  1. The Rapid Response process will meet the requirements of "Working Together to Safeguard Children" and any subsequently agreed SUDC protocols. All evidence of decision making processes throughout the Rapid Response should be documented and presented at Panel meetings for Quality Assurance purposes.
  2. When a child dies unexpectedly, several investigative processes may be instigated, particularly when abuse or Neglect is a factor. The SUDC Protocol intends that the relevant professionals and organisations work together in a coordinated way, in order to minimize duplication and ensure that the lessons learnt contribute to safeguarding and promoting the welfare of children in the future.
  3. If, during the enquiries, concerns are expressed in relation to the needs of surviving children in the family, discussions should take place with Children's Social Care. It may be decided that it is appropriate to initiate an Initial Assessment or make a Referral to Children's Social Care.
  4. The Police must be informed immediately that there is a suspicion of a crime, to ensure that the evidence is properly secured and that any further interviews with family members and other relevant people accord with the requirements of the Police and Criminal Evidence Act 1984.
  5. It is intended that those professionals involved (before or after the death) with a child who dies unexpectedly should come together to enquire into, and evaluate the circumstances of the child's death. The work of the team convened in response to each child's death should be coordinated, usually, by the SUDC Nurse.
  6. Included in this 'team' will be professionals with particular roles and expertise, including, for example (but not exclusively):
    • Paediatrician;
    • General Practitioner;
    • Nurse;
    • Health Visitor;
    • Midwife;
    • Mental Health professional;
    • Social Worker;
    • Probation Officer;
    • Police officer.
  7. This team will also work according to the SUDC protocol agreed with the local Coroner's office. The joint responsibilities of these professionals include:
    • Responding quickly to the unexpected death of a child;
    • Making immediate enquiries into, and evaluating the reasons for and circumstances of the death, in agreement with the Coroner;
    • Undertaking the types of enquiries/investigations that relate to the current responsibilities of their respective organisations when a child dies unexpectedly. This includes liaising with those who have ongoing responsibilities for other family members;
    • Collecting information in a standard, nationally agreed manner;
    • Following the death through and maintaining contact at regular intervals with family members and other professionals who have ongoing responsibilities for other family members, to ensure they are informed and kept up-to-date with information about the child's death.

Reviewing Deaths of all Children

  1. The CSAP considers the deaths of all children and young people from birth (excluding those babies who are stillborn and planned terminations of pregnancy carried out within the law) up to the age of 18 years.
  2. The statutory duty of the CDOP (to review all child deaths), is a paper-based exercise which aims to establish an insight into the circumstances of the child's death and relevant historic factors leading up to the death. This enquiry will allow the panel to establish a cause of death and identify possible contributory factors. As a part of this process, the panel will then identify modifiable risk factors (taking account of factors in the child, the parenting capacity, wider family, environmental and societal factors and services provided to or need by the child or family) and to determine strategies for prevention.
  3. In order to fulfil its responsibilities, the CSAP should be informed of all deaths of children normally resident in its geographical area. The CDOP Coordinator is the designated individual to whom all death notifications or other data relating to deaths should be sent. The Chair of the Overview Panel is responsible for ensuring that this process operates effectively.
  1. Notification of deaths to the CDOP Coordinator is carried out by the paediatric liaison staff (or other similar role within the Hospital Trust). Where a death occurs in a community setting, the professional confirming the fact of death should notify the CDOP Coordinator. Notifications for unexpected deaths will be in line with the Pan-Lancashire SUDC protocol. If the child's death was not in the area the child is normally resident, the CDOP Coordinator should inform their opposite number in the area where the child normally resides. In these situations, it should be decided on a case-by-case basis which Panel should take responsibility for gathering the necessary information for a Panel's consideration. In some cases this may be done jointly.
  2. Any professional (or member of the public) hearing of a local child death in circumstances that mean it may not yet be known about (e.g. a death occurring abroad) can inform the CDOP Coordinator.
  3. The Registrar of Births and Deaths are required by the Children and Young Persons Act 2008 to supply information they have about the deaths:
    • Of persons ages under 18 in respect of whom they have registered the death; or
    • Of persons in respect of whom the entry of death is corrected and it is believed that person was or may have been under the age of 18 at the time of death;

      This notification is sent to the CDOP Coordinator within 7 days of the date of registration, the date of making the correction / update or the date of issuing the certificate of no liability as appropriate.
  4. The Child Death Overview Panel will have a permanent core membership drawn from the key organisations represented on the CSAP, although not all core members are necessarily involved in discussing all cases. The Panel includes professionals from public health, Primary and secondary health care establishments including hospital and midwifery services, Children Safeguarding Partnerships, Children's Social Care, Early Years Services, Paediatrics and Police. Other members may be co-opted, either as permanent members to reflect the characteristics of the local population (e.g. a representative of a large local ethnic or religious community), to provide a perspective from the independent or voluntary sector, or to contribute to the discussion of certain types of death when they occur (e.g. fire fighters for house fires). The Panel Chair provides representation from Public Heath and is not involved in providing direct services to children and families in the area.

Functions of the Child Death Overview Panel

  1. The functions of the Child Death Overview Panel include:
    • Reviewing all child deaths up to the age of 18, excluding those babies who are stillborn and planned terminations of pregnancy carried out within the law;
    • Collecting and collating information on each child and seeking relevant information from professionals and, where appropriate, family members;
    • Discussing each child's case, and providing relevant information or any specific actions related to individual families to those professionals who are involved directly with the family so that they, in turn, can convey this information in a sensitive manner to the family;
    • Determining whether the death was deemed preventable, that is, those deaths in which modifiable factors may have contributed to the death and decide what, if any, actions could be taken to prevent future such deaths;
    • Making recommendations to the CSAP or other relevant bodies promptly so that action can be taken to prevent future such deaths where possible;
    • Identifying patterns or trends in local data and reporting these to the CSAP;
    • Where a suspicion arises that neglect or abuse may have been a factor in the child's death, referring a case back to the CSAP Chair for consideration of whether an SCR is required;
    • Agreeing local procedures for responding to unexpected deaths of children (see The Management of Sudden Unexpected Deaths in Childhood (SUDC)); and
    • Cooperating with regional and national initiatives - for example, with the National Clinical Outcome Review Programme - to identify lessons on the prevention of child deaths.
  2. The CSAP will take responsibility for disseminating the lessons to be learnt to all relevant organisations, ensuring that relevant findings inform the Children and Young People's Plan and acting on any recommendations to improve policy, professional practice and inter-agency working to safeguard and promote the welfare of children.

Duties of the CDOP Chair and Coordinator

  1. The chair of the CDOP is responsible for ensuring that the processes operate effectively. They will, in liaison with the CDOP Coordinator and other professionals:
    • Ensure and monitor the effective running of the notification, data collection and storage systems;
    • Determine meeting dates and send meeting notices to team members;
    • Ensure the panel is provided with information regarding each child death to be reviewed - this information is to be provided to the Panel members 5 working days before the meeting;
    • Ensure that all new CDOP members, ad-hoc members and observers sign a confidentiality agreement;
    • Encourage the sharing of information for effective case reviews;
    • Facilitate resolution of agency disputes - See also Resolving Professional Disagreements (Escalation and Conflict Resolution) Procedure;
    • Ensure minutes are compiled and disseminated from each CDOP meeting;
    • Complete and submit an annual report to the CSAP;
    • Monitor the outcome of recommendations and prevention initiatives and activities.
  2. The Chair of the CDOP will encourage all team members to participate appropriately in meetings and ensure that all statutory requirements are met and maintain a focus on preventative work.
  3. The CDOP meets on a monthly basis for a full day. Alternate month meetings include half a day discussion of Business Issues, the remainder of this day and other full days the Panel carry out a review of all child deaths across Lancashire and Blackburn with Darwen.

Taking action to Prevent Deaths

  1. The most important reason for reviewing child deaths is to improve the health and safety of children and to prevent other children from dying. The CDOP will maintain a focus on prevention through all its work.
  2. Individual deaths and overall patterns of childhood deaths will be evaluated; to identify modifiable risk factors (taking account of factors in the child, the parenting capacity, wider family, environmental and societal factors and services provided to or need by the child or family) and to determine the best strategy for prevention. Strategies may be considered at different levels for example, specific agency, CSAP, Regional or National levels.
  3. Recommendations made by the CDOP will be based on the lessons learnt from the review of child deaths, will be focused on specific, measurable actions and will include plans for monitoring implementation.
  4. The CSAP is required to supply data regularly on every child death to bodies commissioned by the DfE, so that the Department can commission bodies to undertake and publish nationally comparable, anonymised analyses of these deaths.

Data Collection

  1. In order to collect an agreed minimum data set the Department for Education data collection forms are used as a foundation. Locally relevant questions have also been added and approved by the Panel. However, should the original notification forms be submitted, further information will be collated by the CDOP Coordinator. Data will be entered on a secure database. Specific information regarding the presence of another child at the death has also been added to the initial notification form. Consideration must then be given to the welfare of the surviving child and it is the responsibility of the CDOP Coordinator to ensure that a referral to Children's Social Care for support has been made.
  2. For all child deaths, each agency must complete a Form A/B Agency Report Form. This may include; case summaries from health records (including Children & Adult Mental Health Services); case information from Police, Social Care, Education; autopsy reports and results of further investigations; relevant information on the family and reports and results of further investigations; relevant information on the family and social circumstances; scene reports from Police units or accident investigations and information collected by the SUDC Nurses during the Rapid Response process.
  3. The final, collated document will then be shared with the Panel members, for discussion at the next available meeting. At this meeting the Analysis Proforma (Form C) will be completed in order to establish cause of death category, preventability and lessons to be learnt.
  4. As a part of the review process the CDOP will notify the Chair of the appropriate CSAP, the Coroner and the Police of any cases identified where there are previously unrecognised concerns of a criminal or child protection nature.

Working with the Media

  1. Media interest in the work of the CDOP or in individual cases will be dealt with by the press officer for the council area where the child was normally resident. The annual report of the CDOP will be a public document and as such will have no identifiable information contained within. Details of individual case discussions are to be kept confidential and in no circumstances will such details be passed to the press. The press officer will work pro-actively with the media to promote the work of the CDOP alongside that of the CSAP in safeguarding and promoting the welfare of children.