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1.3.2 Child Death Overview Panel Procedure

Contents

1. Introduction

This Procedure sets a minimum standard for a Child Death Overview Panel (CDOP) as outlined inWorking Together to Safeguard Children (2015) and will be under constant review by MKSCB policy and procedure sub committee.

There are two inter-related processes for reviewing child deaths. Either process can trigger a serious case review.

The processes are:

  • A rapid response by a team of key professionals who come together for the purpose of enquiring into and evaluating each unexpected death of a child, this is detailed in the Rapid Response Procedure;
  • An overview of all child deaths (birth up to 18th birthday, excluding babies stillborn) in the LSCB area/s, undertaken by a panel drawn from key organisations represented on the LSCB, this Procedure applies.

Local Safeguarding Children Boards (LSCBs) have a responsibility for convening and maintaining a CDOP.

2. Context

When a child/ren dies within the area in which s/he normally resides, the LSCB must collect and analyse information about each death with a view to identifying:

  • Any case giving rise to the need for a review mentioned in Regulation 5(1)(e) of the Local Safeguarding Children Board Regulations 2006;
  • Any matters of concern affecting the safety and welfare of children in the area of the authority; and
  • Any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area

3. Core Purpose

The CDOP will undertake an overview of all child deaths within the locality. This process uses a standard set of data (see Department for 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:  

  • Case summaries from health records;
  • Case information from police, LA children's social care and education;
  • Post mortem reports.

The CDOP has responsibility for reviewing the deaths of all children, with priority given to those deaths that are both unexpected and unexplained.    

If there is to be a serious case review, it will be undertaken by the LSCB where the child normally resides, with the decision taken by the LSCB Chair.

There will be a fixed core membership on the CDOP, which is drawn from the key organisations represented on the LSCB. There should be senior management representation from: 

  • Director of Public Health or representative;
  • Coroner or Coroner's Officer;
  • Consultant Paediatrician;
  • Children's Social Care;
  • Police Child Abuse Investigation Unit;
  • Child Health Nurse;
  • Midwifery;
  • Education;
  • Ambulance/Paramedic services;
  • Chair of Sub-Committee Serious case review.

Other members will 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 e.g. Fire and Rescue Service, adult mental health services, education/early years, bereavement services etc.

  • Emergency Department medical/nursing staff;
  • Primary Care;
  • Other paediatric input, either hospital or community based, or relevant paediatric sub-specialties;
  • Obstetric staff;
  • Other police representatives including accident investigators;
  • Fire and Rescue Service;
  • Children’s Social Care legal representative;
  • Registrar of Births, Deaths and Marriage;
  • Lay representative.

4. Frequency 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 reflect the number of cases in the LSCB area. 

5. Notification of Child Deaths

Working Together to Safeguard Children (2015) Chapter 5 requires that the LSCB should be informed of all deaths of children normally resident in their geographical area. To ensure this each CDOP must nominate a single point of contact (SPOC) to be informed of all child deaths in their LSCB area, regardless of whether the child is resident in the area. 

The SPOC for Milton Keynes is the CDOP administrator. Notifications should be sent tomkscb@milton-keynes.gov.uk (Telephone number: 01908 254373 and Fax number: 01908 692982).

Local agencies in Milton Keynes responding to a child's death as well as informing the coroner, if needed, must also inform the Child Health Department on 01908 243078. The Child Health Department will then inform the CDOP administrator by telephone of the child's death. The Named Nurse Child Protection in the CCG or Hospital Foundation Trust have responsibility for liaising with involved professionals and ensuring the notification form is completed and sent to the CDOP administrator. The policy public protection desk has a key role in informing the SPOC of child deaths.     

Parental consent is not required for this information to be passed to the Local Safeguarding Children Board. It should only be shared with those who need to know as governed by the Caldicott Principles and the Data Protection Act. Persons with Parental Responsibility 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 would normally be done by the paediatrician confirming the child's death to the parents.     

For notification of unexpected child deaths see the Rapid Response Procedure and 'Communicating the Death of a Child in Hospital'/'Communicating the Death of a Child in the CCG'.  

When a child dies in the area s/he is not permanently resident in, the SPOC for the area in which the child died will inform the SPOC in the area the child normally lived.    

It should be decided on a case by case basis which Panel will take responsibility for gathering the necessary information for a Panel's consideration. In some cases this may be done jointly. The CDOP in the area where the death occurred will normally review the death and liaise with the area of permanent residency where appropriate. The two CDOPs may, in some cases, decide to conduct individual reviews. In these cases, the Chairs of both CDOPs must negotiate management of the two reviews to ensure that there is a uniform response.    

Information sharing between the two CDOPs when a child dies out of his/ her normal residency area is in addition to informing the coroner within one working day, if the death was unexpected (see Rapid Response Procedure).    

The CDOP Chair is responsible for ensuring that this process operates effectively.

6. Functions of the Child Death Overview Panel

Children who die in hospital will normally be reviewed by the CDOP for the area in which they lived.   

The CDOP must review the circumstances of children who are normally resident in the area but who die abroad.    

The key functions of the CDOP are to:

  • Receive notification on all child deaths occurring in the local area;
  • Collect and collate an agreed national minimum data set;
  • Make recommendations for any additional data to be collected locally to be approved by the MKSCB;
  • Seek information from professionals who had involvement with the child before and immediately following the death and, where relevant, the child's family members;
  • Evaluate the routinely collected data on the deaths of all children, and thereby identify lessons to be learnt or issues of concern, with a particular focus on effective inter-agency working to safeguard and promote the welfare of children;
  • Assess all the cases with regard to the threshold criteria to enable specific cases to be reviewed in depth;
  • Ensure that individual case discussions have taken place regarding unexpected child deaths;
  • Monitor the appropriateness of the response of professionals to an unexpected death of a child, reviewing the reports produced by the rapid response team on each unexpected death of a child, making a full record of this discussion and providing the professionals with feedback on their work. Where there is an on-going 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;
  • Scrutinise the recommendations from the reports compiled by the designated doctor for unexpected deaths;
  • Identify any common themes from individual cases and consider these in more depth;
  • Consider whether the death was avoidable, if so how such deaths might be prevented in the future;
  • Identify any patterns or trends in the local data and reports these back to the MKSCB;
  • Alert the Chair of the MKSCB about any deaths where, on evaluating the available information, the CDOP considers there may be grounds to undertake further enquiries, investigations or a serious case review and explore why this had not previously been recognised;
  • Inform the Chair of the MKSCB where specific new information should be passed to the coroner or other appropriate authorities;
  • Provide relevant information to those professionals involved with the child's family so that they, in turn, can convey this information in a sensitive and timely manner to the family;
  • Monitor the support and assessment services offered to families of children who have died;
  • Monitor and advise the MKSCB on the resources and training required locally to ensure an effective inter-agency response to child deaths;
  • Identify any public health issues and consider, with the Director/s of Public Health, how best to address these and their implications for both the provision of services and for training;
  • Co-operate with regional and national initiatives to identify lessons on the prevention of unexpected child deaths;
  • Ensure each partner agency of the MKSCB identifies a senior person with relevant expertise to have responsibility for advising on the implementation of the local procedures on responding to child deaths within their agency.

7. Consent and Confidentiality

Information in CDOP meetings will not be anonymised.    

Parental consent is not required for this information to be passed to the LSCB SPOC. It should only be shared with those who need to know as governed by the Caldicott Principles, the Data Protection Act and Working Together to Safeguard Children - see Information Sharing.    

Persons with Parental Responsibility 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 and followed up with a letter. (see "Rapid Response to an Unexpected Child Death"Procedure)   

All MKSCB member agencies must be aware of the need to share information on all child deaths to enable the MKSCB to carry out its statutory duty.      

Members of the CDOP will sign a confidentiality agreement, including sharing and securely storing information 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. 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.

8. Professional and Family Support

Before the CDOP meets, the Chair should consider what explanatory information is sent to the child's family.    

The CDOP Chair should consider what feedback is given to those professionals involved with the child's family so that they, in turn, can convey this information in a sensitive and timely manner to the family.

The CDOP Chair should ensure that information is also received and evaluated by the CDOP regarding the services and immediate support offered to families of children who have died.    

9. Learning From Child Deaths

The CDOP will monitor and advise the LSCB on the resources and training required locally to ensure an effective inter-agency response to child deaths.       

The CDOP will identify any public health issues and consider, with the Director(s) of Public Health, how best to address these and their implications for both the provision of services and for training.

The CDOP will contribute to regional and national initiatives to identify lessons on the prevention of unexpected child deaths e.g. CEMACH.

The CDOP will submit an annual report to MKSCB.

The MKSCB is responsible for:

  • Disseminating the lessons to be learnt to all relevant organisations;
  • Ensuring that relevant findings inform the Children and Young People's Plan;
  • Acting on any recommendations to improve policy, professional practice and inter-agency working to safeguard and promote the welfare of children;
  • Ensuring that data relating to child deaths is submitted to relevant regional and national initiatives to identify lessons on the prevention of unexpected child deaths.

Notification of Child Death



This page is correct as printed on Tuesday 11th of December 2018 12:23:30 AM please refer back to this website (http://mkscb.procedures.org.uk) for updates.
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