8.4 Child Death Overview Panel (CDOP) Procedure
- The regulations relating to child deaths
- Local framework for responding to child deaths
- Child death overview panel
- Partner agency representation and responsibility
- Frequence of CDOP Meetings
- Deaths of children out of area
- Key functions
- The consent and confidentiality
- Use of child death information to prevent future deaths
- Information sharing in relation to child deaths
- Related Policies, Procedures, and Guidance
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.
The processes are:
[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 (firstname.lastname@example.org). 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.]
The BSCB has a responsibility for convening and maintaining a CDOP.
The regulations relating to child deaths
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:
An unexpected death is defined as the death of an infant or child (less than 18 years old) which:
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
Local framework for responding to child deaths
The framework which each LSCB should have in place for responding to child deaths should include:
Designated paediatrician for child death
Designated Person (DP)/Single point of contact (SPOC)
Notification of a child death
Responsibilities of all agencies
Child death overview panel
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:
The CDOP has responsibility for reviewing the deaths of all children, with priority given to those deaths that are both unexpected and unexplained.
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
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:
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.
The CDOP should have a clear relationship and agreed channels of communication with the local coronial service.
Frequence of CDOP Meetings
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.
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
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.
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.
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.
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.
The CDOP Chair is responsible for ensuring that this process operates effectively.
Children who die in hospital will be reviewed by the CDOP for the area in which they were normally resident.
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.
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.
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.
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.
The key functions of the CDOP are to:
The consent and confidentiality
Information in CDOP meetings will not be anonymised.
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.
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.
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.
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
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.
The LSCB is responsible for:
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
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:
Duty and powers of Coroners to share information
Duty and powers of medical examiners (MEs) to share information
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:
Appendix 1: Child death review process in Buckinghamshire
Appendix 2: Confidentiality Statement
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
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.
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.
 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