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8.4 Child Death Overview Panel (CDOP) Procedure

Contents

Introduction

8.4.1

This procedure sets out the processes to be followed when a child dies in the Buckinghamshire Safeguarding Children Board (BSCB) area, as outlined in the Government guidance Working Together to Safeguard Children.

8.4.2

There are two inter-related processes for reviewing child deaths. Either process can trigger a Serious Case Review (SCR).

8.4.3

The processes are:

  • Rapid response by a team of key professionals who come together for the purpose of enquiring into, and evaluating, each unexpected death of a child.
  • An overview of all child deaths up to the age of 18 years (excluding both those babies who are stillborn and planned terminations of pregnancy carried out within the law) in the Local Safeguarding Children Board (LSCB) area, undertaken by a Child Death Overview Panel (CDOP). This will include children who suffered with life-limiting or life-threatening conditions (LL/LT conditions).

[Reviews of deaths which follow a planned termination under the law (Abortion Act 1967) should not be carried out by CDOPs, even in instances where a death certificate has been issued. If the LSCB has general concerns about local procedures relating to planned terminations, it should contact the Care Quality Commission (enquiries@cqc.org.uk). All other deaths (i.e. excluding those deaths which follow a planned termination of pregnancy under the law) which have been registered as live with the General Registrar's Office should be reviewed by the CDOP.]

8.4.4

The BSCB has a responsibility for convening and maintaining a CDOP.

The regulations relating to child deaths

8.4.5

One of the LSCB functions, set out in Regulation 6 of the Local Safeguarding Children Boards Regulations 2006, in relation to the deaths of any children normally resident in their area is:

  • Collecting and analysing information about each death with a view to identifying:
    • any case giving rise to the need for a review mentioned in Regulation 5(1)(e)
    • any matters of concern affecting the safety and welfare of children in the area of the authority
    • any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area.
  • Putting in place procedures for ensuring that there is a co-ordinated response by the authority, their Board partners and other relevant persons to an unexpected death.
  • The responsibility for determining the cause of death rests with the coroner or the doctor who signs the medical certificate of the cause of death (and therefore is not the responsibility of the CDOP).
  • In reviewing the death of each child, the CDOP should consider modifiable factors, for example, in the family environment, parenting capacity or service provision, and consider what action could be taken locally and what action could be taken at a regional or national level.
  • When a child dies outside of the area in which s/he normally resides, the two LSCBs may, in some cases, decide to conduct individual reviews (see paragraph 8.2).

Definitions

8.4.6

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.
8.4.7

A preventable child death is one in which modifiable factors may have contributed to the death. These are factors which, by means of nationally or locally achievable interventions, could be modified to reduce the risk of future child deaths.

Children with life limiting or life threatening conditions

8.4.8
  • Chronic illness, disability and life-limiting conditions account for a large proportion of child deaths. While it is to be expected that children with LL/LT conditions will die prematurely young, it is not always easy to predict when, or in what manner they will die.
  • Professionals responding to the death of a child with a LL/LT condition should ensure that their response to the families concerned is appropriate and supportive, and does not cause any unnecessary distress. End-of-life care plans may be in place and, where appropriate, families should be supported to choose where their child’s body is cared for after death, e.g. a children's hospice.
  • The unexpected death of a child with LL/LT condition should be managed as for any other unexpected death so as to determine the cause of death and any contributory factors.

Local framework for responding to child deaths

8.4.9

The framework which each LSCB should have in place for responding to child deaths should include:

  • A designated paediatrician for child death.
  • A single point of contact to be informed of all child deaths.
  • A CDOP.
  • A working relationship with the local coroner's office.
  • A rapid response team. The LSCB should assure itself that Board partners have adequate local arrangements for responsible on-call professionals with relevant expertise to function as a multi-agency rapid response service to the unexpected death of a child.
  • The CDOP should include a professional from public health as well as child health.

Designated paediatrician for child death

  • Each clinical commissioning group (CCG) should ensure that the LSCB, through the CDOP, has access to a consultant paediatrician whose designated role is to provide advice on:
    • the commissioning of paediatric services from paediatricians with expertise in undertaking enquiries into unexpected deaths in childhood and the medical investigative services such as radiology, laboratory and histopathology services
    • the organisation of such services.
  • The designated paediatrician for child death may provide advice to more than one CCG, and is likely to be a member of the local CDOP. This is a separate role to the designated doctor for child protection, but does not necessarily need to be filled by a different person. These responsibilities should be recognised in the job plan agreed between the consultant and his or her employer.
  • The designated paediatrician or equivalent is responsible for co-ordinating the multi-agency response to all child deaths in a LSCB area which are unexpected or where the cause of the death is uncertain.

Designated Person (DP)/Single point of contact (SPOC)

  • In order for LSCBs to fulfil their child death reviewing responsibilities, each LSCB should be informed of all deaths of children normally resident in its geographical area. The LSCB Chair should decide who will be the Designated Person (DP) to whom the notification and other data on each death, should be sent (a list of people designated by the CDOP to receive notifications of child death information is available from the Department for Education). The CDOP Chair is responsible for ensuring that this process operates effectively.
  • The DP will also need be informed about the death of a child normally resident in the area but who has died elsewhere, and must inform the relevant other DP about a child death where the child normally resides elsewhere.
  • The Registrar has a duty to send a notification of each child's death to the DP. This should enable the DP to check that he or she has been notified of all child deaths in the area.
  • 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 DP in the LSCB.
  • In Buckinghamshire, the CDOP Coordinator will be the DP/SPOC to be informed of all child deaths in the LSCB area, regardless of whether the child is resident in the area.
  • The CDOP Coordinator can be contacted via secure email.

Notification of a child death

8.4.10
  • National templates are available for LSCBs to use to assist collecting information about child deaths.
  • Buckinghamshire use an online system, eCDOP, for collecting and collating information relating to child deaths. The information collected equates to Forms A–E.
  • For initial notification of a child death, use the link on the CDOP Page on the BSCB website. See Appendix 4 for further information.

Responsibilities of all agencies

8.4.11
  • Local agencies responding to a child's death should inform:
    • the coroner, within one working day as appropriate
    • the paediatrician on-call, who in turn should
      • initiate rapid response if the death is unexpected or the cause of death is uncertain
      • inform the DP
      • inform the designated paediatrician or equivalent.
    • The information can be conveyed to the designated paediatrician or equivalent in a confidential telephone conversation. However, there must be agreement during this call as to who will take responsibility for submitting the child death notification to the DP.
    • The police public protection desk has a key role in informing the designated paediatrician or equivalent, and/or the DP of child deaths.

Child death overview panel

8.4.12

The purpose of a child death overview panel is to undertake an overview of all child deaths within the locality. This process uses a standard set of data (see the Department of Education website) based on information available from those who were involved in the care of the child, both before and immediately after the death, and other sources such as:

  • case summaries from health records
  • case information from the police, local authority Children’s Social Care and education
  • post-mortem reports.
8.4.13

The CDOP has responsibility for reviewing the deaths of all children, with priority given to those deaths that are both unexpected and unexplained.

8.4.14

Where it is felt necessary, the CDOP has a duty to recommend that an SCR should be undertaken by the LSCB. The decision to hold a SCR remains the responsibility of the LSCB where the child normally resides, with the final decision taken by the LSCB Chair (see the BSCB SCR procedure).

Partner agency representation and responsibility

8.4.15

There will be a fixed core membership on the CDOP, which is drawn from the key organisations represented on the LSCB. There should be senior management representation from:

  • Director of Public Health or representative
  • Coroner or Coroner’s Officer
  • Consultant Paediatrician ( SUDI paediatrician )
  • Children’s Social Care
  • Police Child Abuse Investigation Unit
  • Child Health Nurse
  • Midwifery
  • Education
  • Ambulance/Paramedic services
  • CCG/Commissioners Representative
8.4.16

Other members should be co-opted as and when appropriate. This may be so that the membership of the CDOP better reflects the characteristics of the local population, to provide a perspective from the independent or voluntary sector, or to contribute to the discussion of certain types of death, for example:

  • emergency department medical/nursing staff
  • primary care
  • other paediatric input, either hospital or community based, or relevant paediatric sub-specialties
  • obstetric staff
  • other police representatives including accident investigators
  • fire services
  • adult mental health services
  • education/early years
  • bereavement services
  • social services legal representative
  • Registrar of Births, Deaths and Marriage
  • lay representative.
8.4.17

The CDOP Chair is accountable to the LSCB, but should not be involved in providing direct services to children and families in the LSCB area.

8.4.18

Within each organisation represented on the LSCB, a senior person with relevant expertise should be identified as the lead professional with responsibility for implementation of the local procedures on responding to child deaths within their agency. Each organisation should expect to be involved in a child death review at some time.

8.4.19

The CDOP should have a clear relationship and agreed channels of communication with the local coronial service.

Frequence of CDOP Meetings

8.4.20

The CDOP should hold meetings on a regular basis to enable the circumstances of each child’s case to be discussed in a timely manner. The frequency of the meetings should be every two to three months and reflect the number of cases.

8.4.21

The CDOP should ensure that all other processes (e.g. coronial enquiries, legal proceedings, SCRs) have concluded before reviewing a child death, although data collection should continue in the meantime.

Deaths of children out of area

8.4.22

When a child dies in the area s/he is not permanently resident in, the CDOP for the area in which the child died will inform the CDOP in the area the child normally lived. The CDOP in the area where the child was normally resident will review the death and liaise with the area where the child died, to ensure that any lessons learned are shared across both areas.

8.4.23

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. To avoid unnecessary burden on professionals and the child’s family, it is not recommended that the two LSCBs conduct individual reviews.

8.4.24

Information sharing between two CDOPs when a child dies out of his/her normal residency area is in addition to informing the coroner within one working day and immediate notification of the designated paediatrician or equivalent if the death was unexpected, or there is uncertainty about the cause of death.

8.4.25

If a child dies unexpectedly out of his/her normal residency area, the designated paediatricians for unexpected deaths in childhood from both areas will jointly decide on who will lead on the rapid response procedures.

8.4.26

The CDOP Chair is responsible for ensuring that this process operates effectively.

8.4.27

Children who die in hospital will be reviewed by the CDOP for the area in which they were normally resident.

8.4.28

In the case of a Looked After child, the CDOP for the area of the local authority looking after the child should exercise lead responsibility for conducting the death review.

8.4.29

Where a young person dies at work, the Health and Safety Executive should be informed. Youth Offending Teams’ reviews of safeguarding and public protection incidents (including the deaths of children under their supervision) should also feed into the CDOP child death processes.

8.4.30

If there is a criminal investigation, the team of professionals must consult the lead police investigator and the Crown Prosecution Service (CPS) to ensure that their enquiries do not prejudice any criminal proceedings. If the child dies in custody, there will be an investigation by the Prisons and Probation Ombudsman (or by the Independent Police Complaints Commission in the case of police custody). Organisations who worked with the child will be required to cooperate with that investigation.

8.4.31

When a child dies in a secure children’s home, the Prisons and Probation Ombudsman will carry out an investigation. In order to assist the Ombudsman to carry out these investigations, secure children’s homes are required to notify the Ombudsman of the death and to comply with requirements at regulation 40(2) of the Children’s Homes (England) Regulations 2015 to facilitate that investigation.

8.4.32

The CDOP must review the circumstances of children who are normally resident in the area but who die abroad. Notification may not come through normal channels and it may be necessary to use other sources, such as the foreign office or the media, to find out more information and start to review the case.

Key functions

8.4.33

The key functions of the CDOP are to:

  1. Receive notification on all child deaths occurring in the local area.
  2. Collect and collate an agreed national minimum data set.
  3. Seek information from professionals who had involvement with the child before and immediately following the death and, where relevant, the child’s family members.
  4. Ensure that parents and family members are informed that their child’s death will be reviewed and are given the opportunity to contribute to the review process.
  5. Discuss each child’s case, and provide 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.
  6. Evaluate the data available and identify lessons to be learnt or issues of concern, with a particular focus on effective inter-agency working to safeguard and promote the welfare of children.
  7. Determine 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
  8. Ensure that individual case discussions have taken place regarding unexpected child deaths.
  9. Monitor the appropriateness of the response of professionals to an unexpected death of a child, reviewing the reports produced by the rapid response team on each unexpected death of a child, making a full record of this discussion and providing the professionals with feedback on their work. Where there is an ongoing criminal investigation, the CPS must be consulted as to what it is appropriate for the Panel to consider and what actions it might take in order not to prejudice any criminal proceedings.
  10. Scrutinise the recommendations from the reports compiled by the designated doctor for unexpected deaths.
  11. Identify any common themes from individual cases and consider these in more depth.
  12. Consider whether the death was preventable, and how such deaths might be prevented in the future.
  13. Identify any patterns or trends in the local data and reports these back to the LSCB.
  14. Alert the Chair of the LSCB about any deaths where, on evaluating the available information, the CDOP considers there may be grounds to undertake further enquiries, investigations or an SCR, and explore why this had not previously been recognised.
  15. Inform the Chair of the LSCB where specific new information should be passed to the Coroner or other appropriate authorities.
  16. Ensure support is offered to families of children who have died.
  17. Advise the LSCB on the resources and training required locally to ensure an effective inter-agency response to child deaths.
  18. Identify any strategic issues (such as public health, community safety, health and safety) and consider how best to address these and their implications for both the provision of services and for training.
  19. Cooperate with regional and national initiatives to identify lessons on the prevention of unexpected child deaths, e.g. the MBRRACE-UK: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK.

The consent and confidentiality

8.4.34

Information in CDOP meetings will not be anonymised.

8.4.35

Information will be shared in accordance with the Overarching Information Sharing Protocols in existence in each LSCB area. Parental consent is not required for this. It should only be shared with those who need to know as governed by the Caldicott Principles, the Data Protection Act and Working Together.

8.4.36

Persons with parental responsibility (Children Act 1989) should be advised that the child’s death will be subject to a review in order to learn any lessons that may help to prevent future deaths of children. This must be handled sensitively. It should normally be done by the doctor confirming the child’s death to the parents.

8.4.37

All LSCB member agencies must be aware of the need to share information on all child deaths to enable the LSCB to carry out its statutory duty.

8.4.38

Members of the CDOP must sign a confidentiality agreement, including sharing and securely storing information (see Appendix 2 for a Confidentiality Statement) when they join the CDOP. This agreement will be reviewed at each meeting.

8.4.39

In no case will any team member disclose any information regarding team discussion within the CDOP outside the meeting, other than pursuant to the mandated agency responsibilities of that individual or for the purposes of joint investigations. Public statements about the general purpose of the child death review process may be made, as long as they are not identified with any specific case.

Use of child death information to prevent future deaths

8.4.40

The CDOP must submit an annual report to BSCB each year. This information should in turn inform the BSCB annual report. This information should include the total numbers of deaths reviewed, recommendations made by the Panel about required future actions to prevent child deaths, and any further description of the deaths that the Panel deems appropriate. It should also include a review of actions taken to implement the recommendations from the previous year's report, and set out any such recommendations which have not yet been fully implemented which are to be carried forward. Appropriate care should be taken to ensure confidentiality of personal information and sensitivity to the bereaved families. Information which could lead to the identification of individual children or family members should not be included in the annual report. The LSCB annual report should serve as a powerful resource for driving public health measures to prevent child deaths and promote child health, safety and well-being.

8.4.41

The LSCB is responsible for:

  • disseminating the lessons to be learnt to all relevant organisations
  • ensuring that relevant findings inform the Children and Young People’s Plan
  • acting on any recommendations to improve policy, professional practice and inter-agency working to safeguard and promote the welfare of children
  • ensuring that data relating to child deaths are submitted to relevant regional and national initiatives to identify lessons on the prevention of unexpected child deaths e.g. MBRRACE.
8.4.42

The LSCB is also required to supply anonymised data on child deaths to the Department for Education, so that the Department can commission research and publish nationally comparable analyses of these deaths. The primary aims of this research are to support a reduction in the incidence of children whose deaths can be prevented, to improve inter-agency working, and to safeguard and promote the welfare of children.

Information sharing in relation to child deaths

8.4.43

Registrars of Births and Deaths

Registrars of Births and Deaths are required by the Children and Young Persons Act 2008 to supply LSCBs with information which they have about the deaths of:

  • persons aged under 18 in respect of whom they have registered or re-registered the death
  • 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.
  • Registrars must also notify LSCBs if they issue a Certificate of No Liability to Register where it appears that the deceased was or may have been under the age of 18 at the time of death.
  • Registrars are required to send the information to the appropriate LSCB no later than seven days from the date of registration, the date of making the correction/update or the date of issuing the certificate of no liability as appropriate. (The appropriate LSCB is the Board established by the children’s services authority in England within whose area is situated the sub-district for which the register is kept). These requirements only apply in respect of deaths occurring on or after 1 April 2009.
  • In order to support these new responsibilities, it is a statutory requirement for each LSCB to make arrangements for the receipt of notifications from registrars and to publish these arrangements. In order to carry out this responsibility, LSCBs are therefore required to notify the Department for Education of the name and email address for the Child Death Overview DP in each LSCB to whom child death notifications should be sent. This information is published by the Department for Education.
8.4.44

Duty and powers of Coroners to share information

  • The Coroners and Justice Act 2009 and Coroners (Investigations) Regulations 2013 place a duty on coroners to inform the LSCB for the area in which the child died of the fact of an inquest or post-mortem. It also gives Coroners a duty to notify the LSCB for the area in which the child died or where the child's body was found within three working days of deciding to investigate a death or commission a post-mortem and to share information with the LSCBs for the purposes of carrying out their functions, which include reviewing child deaths and undertaking SCRs. Where there is more than one LSCB in a Coroner's area, arrangements should be made between the Coroner and the LSCBs as to which LSCB should be informed of the Coroner's decisions.
  • On receipt of an initial report of a death of a child, the LSCB or LSCBs with an interest in this information should inform the Coroner of the address(es) (including email address(es)) to which future information should be supplied. If any information comes to the attention of an LSCB which it believes should be drawn to the attention of the relevant Coroner, the LSCB should consider supplying it to the Coroner as a matter of urgency (further guidance is available on this).
8.4.45

Duty and powers of medical examiners (MEs) to share information

  • In taking forward the proposed improvements to the process of death certification, the Department of Health will ensure that appropriate interfaces are established with these functions now being delivered by LSCBs. It is anticipated that under the Coroners and Justice Act 2009, MEs will be required to share information with LSCBs about child deaths that are not investigated by a Coroner.
8.4.46

Specific responsibilities of CCGs (Health and Social Care Act 2012)

CCGs should employ, or have arrangements in place to secure the expertise of, consultant paediatricians whose designated responsibilities are to provide advice on commissioning paediatric services from:

  • paediatricians with expertise in undertaking enquiries into unexpected deaths in childhood
  • medical investigative services
  • the organisation of such services.

Appendix

8.4.47

Appendix 1: Child death review process in Buckinghamshire

Click here to download the file on the child death review process in Buckinghamshire

Appendix 2: Confidentiality Statement

Click here to dowmload the confidentiality statement

Appendix 3: Notification to the designated Paediatrician for unexpected deaths in childhood, and the LSCB of a Child's death

Working Together to Safeguard Children (Department for Education, 2015, Chapter 5) sets out a statutory requirement for the Local Safeguarding Children Boards (LSCBs) to review the deaths of all children up to their 18th birthday.

Section 5.7 states that the LSCB should be informed of all deaths of children normally resident in the LSCB’s geographical area. The designated paediatrician for unexpected deaths in childhood (or delegate) will usually do this, and should be notified of all child deaths in the area or of children usually resident in the LSCB area but who die in another area.

Local agencies responding to a child’s death as well as informing the Coroner, if needed, should inform the designated paediatrician for unexpected deaths in childhood (or delegate) for the LSCB area using the attached proforma. Information can be conveyed in a confidential telephone conversation, but there should be agreement during this call as to who will take responsibility for completing the notification via eCDOP. Where the information is passed by telephone, it will be helpful for both parties to have a copy of the proforma in front of them while talking to assist the sharing of information.

The information should be treated in strictest confidence.

Designated paediatricians: via hospital switchboard

Buckinghamshire Safeguarding Children Board         
Email: secure-cdop@buckscc.gcsx.gov.uk
Tel: 01296 383485/01296 382537

The Notification proforma should be completed as fully as possible and submitted the same day. For deaths which occur after 5pm, at weekends or on bank holidays, the Notification proforma should be submitted by 10am the next working day. Parental consent is not required for this information to be passed to the designated paediatrician/LSCB. It should only be shared with those who need to know as governed by the Caldicott Principles, the Data Protection Act and Working Together 2015. Persons with parental responsibility (Children Act 1989) should be advised that the child’s death will be subject to a review in order to learn any lessons that may help to prevent future deaths of children. This must be handled sensitively. This would normally be done by the paediatrician confirming the child’s death to the parents. There is a Lullaby Trust leaflet available to assist parents and others with parental responsibility in understanding the review process and how they can contribute.

A death that is unexpected[1] will require a Rapid Response service or a specific review of circumstances or an unexpected child death meeting as set out in the Rapid Response procedure. 

It will be the responsibility of the designated paediatrician (or delegate) and senior police officer in the case to agree the process that such a response will take. This may involve local authority Children’s Social Care or other agencies as needed.

[1] Defined as a 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 leading to or precipitating the events which led to the death.

Appendix 4: Notification of Child Death

Click here to download the file on the notification of a child's death

Related Policies, Procedures, and Guidance

This page is correct as printed on Thursday 18th of July 2019 11:35:24 PM please refer back to this website (http://bscb.procedures.org.uk) for updates.
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