Child Death Overview Panel

The Child Death Overview Panel (CDOP) includes Child Death Review (CDR) partners within the Local Authority and the Herts and West Essex Integrated Care Board (HWEICB).  As set out in Chapter 6 of Working Together to Safeguard Children (2023) Hertfordshire Community Trust (HCT) statutory requirements in relation to the deaths of any child resident in its area is to:

• Review all child deaths of children normally resident in Hertfordshire, and as indicated, of any non-resident children who have died within Hertfordshire;
• Collate and share the analysis of information from all deaths reviewed with the National Child Mortality Database, NCMD;
• Identify modifiable factors that could be altered to prevent future deaths; and when action is identified that a person or organisation should take, inform them of this;
• Prepare and publish a report on local patterns and trends in child deaths, lessons learnt, and actions taken. 

HCT has also put in place procedures for ensuring there is a co-ordinated response by the authority, its Hertfordshire Safeguarding Children Partnership (HSCP) partners and other relevant persons to an unexpected child death.

The functions of the CDOP set out within 5.2.1 of the Child Death Review: Statutory and Operational Guidance in England (2018) include:

• To collect and collate information about each child death, seeking relevant information from professionals and, where appropriate, family members;
• To analyse the information obtained, including the report from the Child Death Review Meeting (CDRM), in order to confirm or clarify the cause of death, to determine any contributory factors, and to identify learning arising from the child death review process, that may prevent future child deaths;
• To make recommendations to all relevant organisations where actions have been identified which may prevent future child deaths or promote the health, safety and wellbeing of children;
• To notify the Child Safeguarding Practice Review Panel and local Safeguarding Partners when it suspects that a child may have been abused or neglected;
• To notify the Medical Examiner (once introduced) and the doctor who certified the cause of death, if it identifies any errors or deficiencies in an individual child's registered cause of death. Any correction to the child's cause of death would only be made following an application for a formal correction;
• To provide specified data to NHS Digital and then, once established, to the NCMD;
• To produce an annual report for child death review partners on local patterns and trends in child deaths, any lessons learnt, and actions taken, and the effectiveness of the wider child death review process; and
• To contribute to local, regional and national initiatives to improve learning from child death reviews, including, where appropriate, approved research carried out within the requirements of data protection.

In reviewing the death of each child, the CDOP should consider modifiable and contributing factors, for example, in 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 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. CDOP should prepare an annual report of relevant information for the HSCP. This information should in turn inform the HSCP annual report.

Information on child deaths will be gathered by the HCT  on a secure, web-based platform (eCDOP).

Data sent and received by the HCT Team or any other agency will be password protected and/or anonymised as appropriate.

In order to ensure complete gathering of information, the HCT Team  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).

Using the agency login, the notifier of the child's death should complete the electronic notification form (formally Form A) via eCDOP reporting system providing as much detail as is known to them in relation to the child, family and the circumstances of the death, including any professionals known to be involved with the child or family.

This should be completed within 24 hours of the child's death at the same time as the Coroner (in the case of an unexpected death) or Registrar/ICB is notified. This will also send information to the National Child Mortality Data base (NCMD). All families should be allocated a single named point of contact to provide information on the child death review process and who can sign post them to sources of support.

On receiving the Notification Form (formally form A) HCT Child Death Review Team  will send out the information gathering form (formally Form B) to the designated contacts at the relevant agencies listed below.

• Children's Services;
• Police;
• Coroner;
• GP;
• Joint Agency Response (see HSCP Joint Agency Response to Unexpected Child Deaths);
• Schools and Colleges;
• Mental Health and Learning Disability Services;
• Professionals such as Hospital Pediatricians/Hospices etc. and any other agencies involved with the child.

Information gathering forms (formally Form B) will be sent out electronically via eCDOP as soon as possible following the death of the child. Information gathering forms (formally Form B)'s must be completed in full and returned electronically via eCDOP within three weeks.

Draft child death analysis (formally Form C) is completed by the CDRM / PMRT Lead for the organisation notifying the death of the child usually within three months of the child's death, unless there are parallel processes taking place. The exception to this is if the death has been unexpected and there has been a Joint Agency Response (JAR). In this case the responsibility will fall to the Lead Health Professional to ensure there is a coordinated approach with all other elements of the JAR and any information/ investigation forms part of the wider child death review process.

At the CDRM/PMRT meeting the parents' views and questions will be explored and learning from the meeting shared with them via their single point of contact or Lead Health Professional.

Any minutes taken at the meetings will also help inform the draft analysis form. Any substantial delay in obtaining information for any part of the above process should be escalated to the Chair of CDOP.

At the time of death parents or carers will be provided with a copy of 'What we have to do when a child dies' by the organisation that notifies the death. Parents or carers can contribute to any part of the review by asking their single point of contact or Lead Professional to liaise with any part of the process and feedback to them. However, it will not be possible to feedback the final CDOP outcome due to the anonymous nature of the review.

Collated information gathering forms and draft analysis form are sent to all panel members. CDOP members will review each case brought before the panel, utilising the draft analysis form C and updating the meeting with any additional information that has been obtained since the CDRM to:

• Classify the cause of death;
• Identify any modifiable factors;
• Decide on preventability of the death;
• Consider whether to make recommendations and to whom they should be addressed.

Recommendations should then be submitted to the Chair of the CDOP Panel and any other relevant body and the HCT Team should make arrangements to ensure actions are taken.

If CDOP are unable to classify the death or adequately review it, from information available, it should decide whether further information could be obtained. If this is appropriate the case review should be rescheduled.

Once the final analysis form is completed this is then submitted to NCMD via eCDOP, ideally this should be no longer than six months after the child's death. However, this is not always possible due to parallel processes, e.g. criminal proceedings.

HCT Child Death Review Team Contact Details:

Hertfordshire Community NHS Trust
Sandridge Gate Business Park
Ronsons Way
St Albans
AL4 9XR
Email: hct.hertscdr@nhs.net 
Telephone: 01727 222769