8.1 Reviewing Deaths of All Children - Role of the Child Death Overview Panel

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This chapter should be read in conjunction with the Unexpected Death of a Child Procedure.


This chapter was updated in May 2016 to include information on the role and functions of the Child Death Overview Panel (CDOP). Links to the Child Death Notification forms were also added to this chapter.


1. Introduction

The Surrey Safeguarding Children Board (SSCB) has responsibility for reviewing the deaths of all children other than still births or planned terminations that are within the law through the arrangements of a Child Death Overview Panel (CDOP). The Panel will have a fixed core membership drawn from organisations represented on the SSCB with flexibility to co-opt other relevant professionals to discuss certain types of death as and when appropriate. The Panel should include a professional from Public Health as well as Child Health. It should be chaired by the SSCB Chair's representative.

In order to fulfil its responsibilities it should be informed of all deaths of children, normally resident in the geographical area.

Completion of the Child Death Notification Forms (see which can be found on the SSCB website) is the responsibility of the Consultant Paediatrician /Clinician confirming the death. This can be done in collaboration with other colleagues, Named Nurses for Safeguarding and Liaison Health Visitors, as well as professionals from other agencies e.g. Police, Surrey Children's Services. The completed forms should be sent, within 24 hours of the death, to the CDOP co-ordinator:

The Chair of the Overview Panel is responsible for ensuring that this process operates effectively. 

2. Notification of a Child’s Death

Deaths should be notified by the professional confirming the fact of the child’s death. For unexpected deaths this will be at the same time as they inform the Coroner, the Designated Paediatrician and Specialist Nurse for unexpected deaths in childhood. The CDOP co-ordinator should be notified as soon as possible and within 24 hours of the death, via email

See SSCB web pages for Child Death Notification Form A and Agency Report Form B.

The Surrey Safeguarding Children Board (SSCB), through the Child Death Overview Panel, should be notified of all child deaths in Surrey. If this is not the area in which the child is normally resident, the Designated person via the Child Death Coordinator should inform their opposite number in the area where the child normally resides. In these situations 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.

The notification sent to the CCG by the Registrar and ONS respectively will provide a check to ensure that all child deaths have been notified. Data sent and received by the CDOP Coordinator and/or SSCB Support Team or any other agency will be password protected and/or anonymised as appropriate.

In order to ensure complete gathering of information, the CDOP Coordinator will receive notifications from a number of sources including the Clinical Commissioning Group(s); the Registrar of Births, Deaths and Marriages; the Coroner(s); Emergency Departments; Paediatricians; and the Police Force(s).

Form A’s and B’s are held by the notifying agencies and are to be sent securely to the CDOP Coordinator by email. They are also available on the SSCB website.

3. Child Death Overview Panel

The Child Death Overview Panel will have a permanent core membership drawn from the key organisations represented on the Board although not all core members will necessarily be involved in discussing all cases. It should include a professional from Public Health as well as Child Health.

Other members may be co-opted to contribute to the discussion of certain types of death when they occur (for example, Fire and Rescue for house fires).

The functions of the Child Death Overview Panel include:

  • Reviewing all child deaths, (excluding babies who are stillborn and planned terminations of pregnancy carried out within the law)will determine whether the death was 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. This decision should always be approved by the Chair of the CDOP;
  • Making recommendations to the LSCB or other relevant bodies promptly so that action can be taken to prevent future such deaths where possible;
  • Implementing, in consultation with the local Coroner, local procedures and protocols which are in line with this guidance on enquiring into unexpected deaths and evaluating these together with information about all deaths in childhood;
  • Collecting and collating information on each child  and seeking relevant information from professionals and, where appropriate, family members;
  • Meeting frequently to review and evaluate the routinely collected data and identifying lessons to be learnt or issues of concern with a particular focus on effective interagency working to safeguard and promote the welfare of children;
  • Evaluating specific cases in depth, where necessary, at subsequent meetings. This may involve revisiting child deaths after the outcome of other types of investigations is known (for example, outcomes from Serious Case Reviews, criminal proceedings or Inquests;);
  • Monitoring the appropriateness of the response of professionals to an unexpected death of a child;
  • Reviewing the reports produced by the joint agency team on each unexpected death of a child, including the extent to which the team has brought together any recorded wishes and feelings of the family, making a full record of this discussion and providing the professionals with feedback on their work;
  • Where there is an on-going criminal investigation, CPS must be consulted to ensure that their enquires do not prejudice any criminal proceedings;
  • Referring to the Chair of the SSCB any deaths where, on evaluation of available information, the Panel considers there may be grounds for further enquiries, investigations or a Serious Case Review and explore why this had not previously been recognised;
  • Informing the Chair of the SSCB where specific new information should be passed to the Coroner or other appropriate authorities;
  • 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;
  • Monitoring the support and assessment services offered to families of children who have died;
  • Monitoring and advising the SSCB on the resources and training required to ensure an effective inter-agency response to child deaths;
  • Organising and monitoring the collection of data for the nationally agreed data set and making recommendations (to be approved by LSCBs) for any additional data to be collected locally;
  • Identifying patterns or trends in local data and reporting these to the LSCB;
  • Identifying any public health issues and considering, with the Director(s) of Public Health, how best to address these and their implications for both the provision of services and for training; and
  • Co-operating with regional and national initiatives for example, with the National Clinical Outcome Review Programme - to identify lessons on the prevention of child deaths.

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

The Child Death Overview Panel work plan will be approved by the SSCB. The aggregated findings from all child deaths should inform local strategic planning, including the local Joint Strategic Needs Assessment, on how to best safeguard and promote the welfare of children in the area. The CDOP will prepare an annual report for the SSCB. This information should in turn inform the SSCB annual report which will have responsibility for publishing relevant, anonymised information.

The SSCB will disseminate the lessons to be learnt to all relevant organisations, ensure relevant findings inform the Children and Young People’s Plan and act on any recommendations to improve policy, professional practice and inter-agency working to safeguard and promote the welfare of children.

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