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4.2 Reviewing All Childhood Deaths


This chapter should be read alongside, the procedure for the Investigation of Sudden Unexpected Deaths in Childhood.


  1. Introduction
  2. Procedure

1. Introduction

Chapter 5 of Working Together to Safeguard Children sets out the responsibilities of Local Safeguarding Children Boards (LSCBs) to review all deaths of children under 18, and explains  the role and functions of the Child Death view Panel (CDOP) in terms of notification, data collection and monitoring, information sharing, meetings, case discussions and classification.

The purpose of the child death review process is to gain an understanding of the circumstances of the child's life and death, including the possibility that the child may have suffered abuse or neglect (and thus providing a safety net to identify potential Serious Case Reviews). In addition the review process contributes to the learning of common lessons which is useful in the formulation of public health strategies.

The exercise will largely be paper based but will involve the convening of regular standing panel discussions to consider individual cases.

Functions of the Child Death Overview Panel (CDOP) include:

  • Reviewing all child deaths, excluding those babies who are stillborn and planned terminations of pregnancy carried out within the law;
  • Collecting and collating information on each child, their family and home environment. This will involve 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 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 LSCB 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 LSCB;
  • Where a suspicion arises that neglect or abuse may have been a factor in the child’s death, referring a case back to the LSCB Chair for consideration of whether a Serious Case Review is required;
  • Identifying any public health issues and considering, Public Health Lead, how best to address these and their implications for both the provision of services and for training
  • Agreeing local procedures for responding to unexpected deaths of children in line with Working Together to Safeguard Children; and
  • Co-operating with regional and national initiatives to identify lessons on the prevention of child deaths.

2. Procedure

2.1 General

The LSCB will discharge its responsibilities via the CDOP convened and chaired by the LSCB chair or his/her representative who must be a member of the LSCB.

If the child is normally resident outside the area covered by the LSCB, the chair or designated coordinator (Business Manager) will ensure that their opposite number in the relevant LSCB area is informed and sent the information.

The death will normally be reviewed by the Panel of the area where the child is usually resident. Exceptional cases will be discussed on a case by case basis.

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).

2.2 Notification

Deaths, from birth to 18th birthday, should be notified to the local LSCB CDOP co-ordinator by the person certifying the death; or via any other agreed local arrangement.

The LSCB will designate a coordinator of the Board to receive notifications on its behalf.

The Chair of the CDOP is responsible for ensuring the notification process works well.

All agencies must notify the local CDOP if any appeals process or complaint is brought in respect of a child death, or if any serious incident or other investigation has or is due to take place.

2.3 Data Collection

Each LSCB will be responsible for organising and monitoring the collection of data for the nationally agreed minimum data set, and making recommendations for any additional data to be collected locally;

Following notification of a child's death, the designated coordinator will organise the distribution of the agency report forms to all relevant local agencies, as determined by local procedures and the circumstances of the death.

Completed agency report forms will be returned, collated and recorded by the coordinator. Anonymised agency report forms will be made available to Panel members for discussion.

Where a Post Mortem examination has taken place, the Coroner will be requested to send post-mortem and other relevant reports for each child death.

All transfer of data and information sharing must comply with the national information sharing standards.

See Child Death Reviews – Forms for Reporting Child Deaths.

2.4 Parental Involvement

Consideration will be given by the LSCB as to the degree of involvement of families. Parents are not invited to be part of the Panel, however they may be asked to contribute any comments they wish to make into the review of their child.

2.5 Panel Meetings

The CDOP will meet 3 monthly or more frequently if this proves necessary.

LSCBs may adopt flexible local arrangements to review neonatal deaths or the deaths of children that never left hospital.

Panel membership will reflect the organisations represented on the LSCB, with co-optees invited as required on a case by case basis. The core membership and co-optees will be determined by local procedures and by the individual circumstances of the child's death.

Panel members will consider the anonymised and collated reports and any other relevant information.

CDOP’s should determine the minimum number of professionals who must be present to appropriately review a child death.

2.6 Annual Report

The work of the Panel will be presented in the form of an annual report to the LSCB.