Child death review process
The purpose of the Child Death Review Process
The purpose is to collect information about the deaths of all children in the area so the Child Death Overview Panel can document, analyse and review information in relation to each child that dies in order to confirm the cause of death, determine any contributing factors and to identify learning arising from the process that may prevent future child deaths:
- to make recommendations to all relevant organisations where actions have been identified which may prevent future deaths or promote the health, safety and wellbeing of children
- to contribute to local, regional and national initiatives to improve learning from Child Death Reviews
What the Child Death Overview Panel is
CDOP is a multi-agency panel responsible for reviewing information on all child death’s up to the age of 18 in Cumbria.
Who is on the Child Death Overview Panel
The Panel is chaired by an independent person and has representatives from:
- Local Authority Children’s Services and Education
- Child Health Services such as paediatrics, nursing, general practitioners and midwifery
- Police
On occasion the Panel co-opt experts to assist their information gathering and analysis when needed.
How the reviews happen
The Child Death Overview Panel meet bi-monthly. All the information presented to the Panel is anonymised, strictly confidential and is treated with sensitivity and respect.
How we involve parents and family members in the review
The parents of each child receive a letter along with an NHS England Child Death Review booklet following the death of their child. Both advise them about the Child Death Review Process and how they can express their views and contribute into it if they wish.
How the Panel report its findings
The Child Death Overview Panel provide an annual report to the Cumbria CSCP Board and Safeguarding Lead Partners. This is a publicly available document, which is published on the Cumbria CSCP Website.
All reports prepared by the Panel are based on aggregated information, and no personal case information is included in them.
The Panel will be seeking sensitive confidential information about the child and other family members.
The statutory framework that underpins this information is laid down in Chapter 5 of Working Together to Safeguard Children (2018).
Cumbria Joint Agency Response
It is the responsibility of the Local Authority and Morecambe Bay and North Cumbria Clinical Commissioning Groups (CCG’s) to ensure that a review of each death of a child normally resident in its area is undertaken by CDOP.
What an ‘Unexpected Death' is
Working Together to Safeguard Children 2018, Chapter 5 defines the unexpected death of a child which was not anticipated as a significant possibility 24 hours before the death, or where there was a similarly unexpected collapse leading to or precipitating the events that led to the death.
Purpose of a joint agency response meeting
Joint Agency Response describes the process of communication, collaborative action and information sharing following the unexpected death of a child. The purpose of a Joint Agency Response meeting is to ensure that the appropriate agencies engage and work together to:
- respond quickly to the unexpected death of a child
- make immediate enquiries into and evaluate the reasons for and circumstances of the death, in agreement with the coroner
- undertake enquiries/investigations that relate to the current responsibilities and actions of each organisation when a child dies unexpectedly. This includes liaising with those who have ongoing responsibilities for other family members
- collate information in a standard, nationally agreed manner
- work together appropriately post death, keeping contact with family members via an identified key worker to ensure that they are appropriately supported and informed of all information concerning their child
Joint Agency Response begins at the point of death and ends with the completed report to the Child Death Overview Panel. The first phase of the response will be within the first few hours when an information sharing and planning discussion or meeting takes place most usually between the Consultant and hospital staff, the Police and the Coroner.
The second phase brings together a multi-agency team for a ‘Joint Agency Response’ meeting which should take place within 72 hours after the unexpected death of a child. The professionals involved will carry out their normal functions for example as a GP, Paediatrician, Midwife, Health Visitor, Police Officer or Social Worker, but will work in accordance with the guidance within Working Together to Safeguard Children 2018.
This guidance has been developed locally and is contained within the Cumbria CDOP Procedures.
A ‘Child Death Review’ meeting brings together all the professionals involved and takes place after the post-mortem examination results are complete, but prior to an Inquest (where applicable).
Following the Inquest (if applicable) each case is reviewed by the Child Death Overview Panel to:
- classify the cause of death
- identify any modifiable factors
- consider whether to make recommendations and whom they should be addressed by