11.2 Child Death Overview Panel (West Sussex)

The functions of the Child Death Overview Panel (CDOP) are set out in governmental guidance:Working Together to Safeguard Children 2015, Chapter 5, Section 8 . See also West Sussex CDOP Terms of Reference.

The Local Safeguarding Children Board has a responsibility for convening and maintaining a Child Death Overview Panel (CDOP) which will meet on a regular basis and undertake an overview of the deaths of all children, excluding those who are stillborn, from birth to age 18 years.

To receive notifications of the deaths of all children from birth to 18 years in West Sussex. Notifications will come from a number of sources including the Police, Ambulance Service, Accident and Emergency Departments, Paediatricians, NHS Community Services, Fire and Rescue service, the Registrar of Births, Deaths and Marriages, the Coroner and palliative care centres. In cases where organisations in more than one LSCB area have known about or have had contact with the child, lead responsibility should sit with the LSCB for the area in which the child was normally resident at the time of death. Other LSCBs or local organisations which have had involvement in the case should cooperate in jointly planning and undertaking the child death review. In the case of a looked after child, the LSCB for the area of the local authority looking after the child should exercise lead responsibility for conducting the child death review, involving other LSCBs with an interest or whose lead agencies have had involvement as appropriate. (Working Together to Safeguard Children 2015, Chapter 5, Section 5).

To collect a core data set of information relating to each child’s death. A data collection tool will be sent to the agency which made the notification and other key professionals. These Agency Reports may include: case summaries from health records, case information from police, social care and education; post mortem reports and results of further investigations; relevant information on the family and social circumstances; scene reports from police or accident investigation units. Data returned will be entered on a secure database.

To receive reports from other reviews of child deaths, including individual reviews of Sudden Untoward Incidents, hospital reviews of perinatal deaths and  Serious Case Reviews.

To produce a work plan, submitted for approval by the LSCB(s).

To classify each death in terms of preventability.

To review annually the numbers and patterns of deaths in West Sussex.

To notify the chair of the LSCBs, the coroner and the police of any deaths(s) identified where there are previously unrecognised concerns of a criminal or child protection nature.

To identify any lessons to be learnt from individual reviews or reviews of overall patterns and trends, including any system or process issues and any health, public health and safety issues.

To monitor professional responses to child deaths, and identify good practice and any gaps or deficiencies in the process.

To provide LSCB and its constituent agencies with an annual report including any recommendations for future practice and reducing the number of preventable deaths.

To provide to the LSCBs any relevant findings that can be used to inform the respective Children and Young People’s Plans. The CDOP will supply data as required to the Department for Education (DfE) on behalf of the LSCBs.

The annual report on the work of the CDOP issued by the LSCBs will aim to be a public document containing no identifiable information.  Details of discussions of individual children are to be kept confidential.

The CDOP has a fixed core membership with the flexibility to co-opt other relevant professionals as set out in Working Together to Safeguard Children 2015, Chapter 5, Section 3  and West Sussex CDOP Terms of Reference.

Each partner agency will identify a senior person with relevant expertise to have responsibility for advising on the implementation of the procedures on responding to child deaths within their agency.

The Coroners (Investigations) Regulations 2013 places a duty on coroners to inform the LSCB for the area in which the child died or the child’s body was found, where the coroner decides to conduct an investigation or  directs that a post mortem should take place. The coroner must provide to the LSCB all information held by the coroner relating to the child’s death.

Where the coroner makes a report to prevent other deaths, a copy must be sent to the LSCB

The Children and Young Persons Act 2008 requires Registrars of births and deaths to supply LSCBs information about child deaths within seven days of registration.

All members and observers of CDOP proceedings must sign a Confidentiality Agreement. This agreement will be reviewed and updated annually by the CDOP.

Information discussed in CDOP meetings will be not be anonymised, but after the meeting all documents will be destroyed except for the anonymised records that will be kept by the CDOP Co-ordinator.

All LSCB members must be aware of the need to share information on all child deaths to enable the LSCBs to carry out their statutory duties.

West Sussex CDOP will meet on a two-monthly basis or as is required to enable each child to be discussed in a timely manner.

The Core membership of West Sussex CDOP may be expanded to include representatives from user led groups.

The CDOP Chair should encourage members to form a consensus. Where a consensus cannot be reached, the Chair’s decision is final.

Each death should be notified to the ‘Single Point of Contact’ (SPOC) for West Sussex. Individual professionals should notify the SPOC at the same time as they notify the Coroner (in the case of an unexpected death) or Registrar / Health Services. Click here to view the current contact details for all SPOCs, including West Sussex.

The Single Point of Contact is responsible for maintaining a data base of information about all child deaths of children normally resident in West Sussex. For children who die in West Sussex  but who are normally resident in other LSCB areas the SPOC will notify the LSCB Single Point of Contact for the area in which they (or in the case of newborn babies their mother) normally reside.

For deaths occurring in an area different to that of the child’s normal residence, an agreement must be reached between the two CDOPs as to which Panel will review the death. Normally, this will be the CDOP for the area of usual residence. Arrangements must be made for the other Panel to be advised of the outcome of the Review.

In West Sussex information is collected using the templates produced by the Department for Education in order to enhance consistency between LSCBs.

Form A is for the Initial Notification of the child’s death. Form B is for each Agency’s information. Form C is for use by the CDOP to analyse the information presented and make recommendations.

Other forms available from the Department for Education and used by West Sussex CDOP are for use in specific circumstances.

The CDOP will ensure that all families are informed of the CDOP process and the most appropriate professional in contact with the family will invite them to contribute to the discussion.

Where the Single Point of Contact is notified of a child normally resident in West Sussex but who has died in another Local Authority area, (s)he will immediately notify the Specialist Nurse Rapid Response for West Sussex.

The police and Coroner must be informed immediately that there is a suspicion of a crime or evidence comes to light that the death may be of a suspicious nature.  The Chair of the LSCB should be informed to ensure that appropriate procedures are followed and to consider the need for a Serious Case Review. Where there is an ongoing criminal investigation, the Crown Prosecution Service must be consulted as to when/what is appropriate for the Panel to consider and what actions it might take in order not to prejudice any criminal proceedings. 

If, during the enquiries, concerns are expressed in relation to the needs of surviving children in the family, immediate discussions should take place with Children’s Social Care. It may be decided that it is appropriate to initiate a Child and Family Assessment. If concerns are raised at any stage about the possibility of surviving children in the household being abused or neglected, the inter-agency procedures set out in Chapter 1 of Working Together to Safeguard Children 2015 (links) and in Part 3 of this manual, Recognition and Referral of Abuse and Neglect should be followed. (links)

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. 

Individual deaths and overall patterns of childhood deaths will be evaluated to decide if the deaths were preventable; to identify modifiable risk factors (factors in the child, the parenting capacity, wider family, environmental and societal factors, and services provided to or needed by the child or family); and to determine the best strategy/strategies for prevention.

Strategies may be considered at different levels:

• Strengthening Individual knowledge and skills: assisting individuals to increase their knowledge and capacity to act, leading to behaviour change, through education, counselling and individual support;
• Promoting Community Education;
• Training Providers to improve knowledge, skills, capacity and motivation to effectively promote prevention;
• Fostering coalitions and networks of individuals and organisations to work for advocacy and health promotion;
• Changing organisational practices where system failures are identified, or models of good practice highlighted;
• Mobilising neighbourhoods and communities in the process of identifying, prioritising, planning and making changes;
• Influencing policy and legislation where appropriate through local and national advocacy.

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.