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Child Death Overview Panel

As set out in Chapter 5 of Working Together to Safeguard Children (2018) Hertfordshire Safeguarding Children Partnership (HSCP) function in relation to the deaths of any child resident in its area is to:

  • Collate and analyse information about each death with a view to identifying any case that requires a Local Child Safeguarding Practice Review;
  • Identify any matters of concern affecting the safety and welfare of children in the area; and
  • Explore any wider public health or safety concerns arising from a particular death or pattern of deaths.

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

The functions of the CDOP include:

  • Reviewing all deaths of children normally resident in Hertfordshire from birth to18 years excluding those babies who are stillborn and planned terminations of pregnancy carried out within the law;
  • To cooperate with other CDOP processes if a non-resident child dies in Hertfordshire;
  • Collecting and collating information on each child and seeking relevant information from professionals and, where appropriate, family members using a standard set of data;
  • Discussing each child’s case, providing relevant information or any specific actions related to individual families to identify professionals who are involved directly with the family so that they, in turn, can convey this information in a sensitive manner to the family;
  • Determining whether the death was deemed 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;
  • Making recommendations to the HSCP or other relevant bodies promptly so that action can be taken to prevent future such deaths where possible;
  • Identifying patterns or trends in local data and reporting these to the HSCP;
  • Where a suspicion arises that neglect or abuse may have been a factor in the child’s death, referring a case back to the HSCP Chair for consideration of whether a Local Child Safeguarding Practice Review is required;
  • Agreeing local procedures for responding to unexpected deaths of children; and
  • Cooperating with regional and national initiatives – for example, with the National Clinical Outcome Review Programme - to identify lessons on the prevention of child deaths and National Child Mortality Database NCMD.

In reviewing the death of each child, the CDOP should consider modifiable 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 Hertfordshire Safeguarding Children Partnership (HSCP) Business Unit on a secure, web-based platform (eCDOP).

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

In order to ensure complete gathering of information, the HSCP Business Unit 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) the HSCP Business Unit 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;
  • Rapid 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) are 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 ‘When a Child Dies: A guide for parents and carers’ 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 HSCP Panel and any other relevant body and the HSCP 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.

HSCP Business Unit Contact Details:

Room 147
County Hall
Pegs Lane
SG13 8DF

Last Updated: December 7, 2023