7.2 Child Death Overview Panel - Operational Procedures

Definition of preventable child death
Core Functions of the Child Death Overview Panel
Confidentiality and Information Sharing
Child Protection Concerns
Taking Action to Prevent Child Deaths
Working with the Media
Duties of the CDOP Chair and KSCB Business Manager

1. Definition of preventable child death

For the purpose of producing aggregate national data, this guidance defines preventable child deaths as those in which modifiable factors may have contributed to the death. These factors are defined as those which, by means of nationally or locally achievable interventions, could be modified to reduce the risk of future child deaths.

In reviewing the death of each child, the CDOP should consider modifiable factors, for example in the family and 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.

2. Core Functions of the Child Death Overview Panel

To receive notifications of the deaths of all children from birth to 18 years in Knowsley. In order to ensure complete notification, these notifications will come from a number of sources including the Primary Care Trust(s); the Registrar of Births, Deaths and Marriages; the Coroner(s); Emergency Departments; Paediatricians; and the Police Force(s). Individual professionals will notify the KSCB Business Manager/ Administrator at the same time as they notify the coroner (in the case of an unexpected death) or Registrar / PCT. Each death should be notified to the CDOP of the area in which the child (or mother in the case of a neonatal death) was normally resident. If a different team (for example the CDOP for the area in which the child died) is notified, the LSCB /CDOP manager should notify their counterpart in the area of residence. For deaths occurring in an area different to that of the child's normal residence, an agreement must be reached between the two LSCB managers/CDOP chairs as to which team will review the death (normally the CDOP for the area of residence) and how the other team will be notified of the outcome.

Still births and planned terminations that are within the law are not considered by the Child Death Overview Panel.
To collect a core data set of information relating to each child's death. A data collection tool will be sent to the notifier and other key professionals. Data returned will be entered on a secure database. In addition to the core data set, for deaths requiring more in-depth review, further information will be sought from all involved agencies. This may include: case summaries from health records; case information from police, social care and education; autopsy reports and results of further investigations; relevant information on the family and social circumstances; scene reports from police child abuse investigation units or accident investigators.
To meet on a regular basis to review specified child deaths, drawing on comprehensive information from all agencies on the circumstances of each child's death. This information will be reviewed by the team in order to meet the objectives set out above. Whilst all deaths will be notified to the team and a core data set collected, not all deaths will be reviewed in detail. Particular consideration shall be given to the review of sudden unexpected deaths in infancy and childhood; accidental deaths; deaths related to maltreatment; suicides; and any deaths from natural causes where there are potential lessons to be learnt about prevention. The team will determine and review on a regular basis which deaths are to be reviewed in an in-depth manner.
To receive reports from other reviews of child deaths, including individual case reviews for SUDI, and hospital reviews of perinatal deaths.
To review annually the numbers and patterns of deaths in Knowsley.
To notify the chair of the KSCB, the coroner and the police of any cases 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 public health issues.
To monitor professional responses to child deaths, and identify good practice as well as any gaps or deficiencies in the process.
To make appropriate recommendations to the KSCB.
To provide the KSCB and constituent agencies with an annual report on the work of the team.

3. Confidentiality and Information Sharing

Information discussed at the CDOP meetings will not be anonymised prior to the meeting, it is therefore essential that all members adhere to strict guidelines on confidentiality and information sharing. Information is being shared in the public interest for the purposes set out in Working Together and is bound by legislation on data protection.

CDOP members will all be required to sign a confidentiality agreement before participating in the CDOP. Any ad-hoc or co-opted members and observers will also be required to sign the confidentiality agreement. At each meeting of the CDOP all participants will be required to sign an attendance sheet, confirming that they have understood and signed the confidentiality agreement.

Any reports, minutes and recommendations arising from the CDOP will be fully anonymised and steps taken to ensure that no personal information can be identified.

4. Child Protection Concerns

Where there is an ongoing criminal investigation, the Crown Prosecution Service 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.

If, during the enquiries, concerns are expressed in relation to the needs of surviving children in the family, discussions should take place with LA children's social care. It may be decided that it is appropriate to initiate an initial assessment using the Framework for the Assessment of Children in Need and their Families (2000). 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 5 of Working Together to Safeguard Children 2010 should be followed. 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 KSCB should be informed of the case to ensure that appropriate procedures are followed and to consider the need for a Serious Case Review.

The Youth Justice Board for England and Wales (YJB) requires Youth Offending Teams (YOTs) to report and undertake local reviews of youth offending practice in cases where a child or young person has either died or attempted suicide whilst under supervision or within three months of the expiry of supervision. Where a child has died, the Local Management Review undertaken by the YOT in relation to the death should feed into the child death processes initiated by the CDOP.

5. Taking Action to Prevent Child Deaths

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 determine if the deaths were preventable; to identify modifiable risk factors (taking account of 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(ies) 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 Organizational Practices where system failures are identified, or models of good practice highlighted.
Mobilizing 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.

6. Working with the Media

Media interest in the work of the CDOP or in individual cases will be dealt with by the press officer for the LSCB. The annual report of the CDOP will be a public document and as such will have no identifiable information contained within. Details of individual case discussions are to be kept confidential and in no circumstances will such details be passed to the press. The LSCB press officer will work proactively with the media to promote the work of the CDOP alongside that of the LSCB in safeguarding and promoting the welfare of children in (the Local Authority area).

7. Duties of the CDOP Chair and KSCB Business Manager

The KSCB Chair should decide who will be the designated person to whom the death notification and other data on each death should be sent. The Chair of the Overview Panel is responsible for ensuring that this process operates effectively.

The CDOP Chair will be responsible for the smooth running of all child death review processes. He/she will:

Ensure and monitor the effective running of the notification, data collection and storage systems
Following notification there will be a discussion with the KSCB Business Manager/ Chair of Serious Incident Review Group (SIRG) to identify cases where the SIRG should convene
Determine meeting dates and send meeting notices to team members.
Obtain names and compile the summary sheet of child deaths to be reviewed and distribute to team members two to three weeks prior to each meeting.
Ensure that notifications of child deaths are available for team review.
Ensure that new members receive an orientation to the Panel prior to their first meeting.
Ensure that all new CDOP members, ad hoc members and observers sign a confidentiality agreement.
Encourage the sharing of information for effective case reviews.
Chair the CDOP meetings encouraging all team members to participate appropriately, ensure that all statutory requirements are met, and maintain a focus on preventive work.
Facilitate resolution of agency disputes.
Compile and disseminate notes from each CDOP meeting
Complete and submit an annual report to the KSCB
Monitor the outcome of recommendations and prevention initiatives and activities.

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