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Derby and Derbyshire Safeguarding Children Boards' Procedures Manual

Child Death Reviews


This chapter outlines the key points and processes involved in responding to unexpected child deaths, and reviewing all child deaths. It should be read in conjunction with Response to Sudden Unexpected Death in Childhood in Derby City and Derbyshire Protocol (Documents Library, Protocols).

Acknowledgments - We acknowledge Leicester, Leicestershire and Rutland CDOP procedures, on which these procedures are based upon.


Serious Case Reviews Procedure


Response to Sudden Unexpected Death in Childhood in Derby City and Derbyshire Protocol (Documents Library, Protocols)

Please Note: Working Together to Safeguard Children – Following publication in July of the revised statutory guidance Working Together to Safeguard Children (2018), the Derby and Derbyshire Safeguarding Children Boards’ Procedures will be reviewed by local partner agencies, and updated as required to reflect the new guidance. In the meantime these procedures continue to reflect practice locally and must be followed when responding to safeguarding concerns about a child. Under the Children and Social Work Act 2017, Serious Case Reviews will be replaced by new national and local arrangements for reviewing serious cases. LSCBs must continue to carry out all their statutory functions, including commissioning SCRs, until the point at which safeguarding partner arrangements begin to operate in a local area.

This chapter is currently under review.


  1. Introduction
  2. Context
  3. Supply of Information about Child Deaths by Registrars
  4. Duty and Powers of Coroners to Share Information
  5. Definitions
  6. Core Purpose
  7. Membership
  8. Frequency of CDOP Meetings
  9. Key Functions
  10. Notification of Child Deaths
  11. Deaths of Children Out of Area
  12. Consent and Confidentiality
  13. Family and Professional Support
  14. Learning from Child Deaths
  15. Reporting Mechanisms

1. Introduction

As outlined in Working Together to Safeguard Children 2015, there are two inter-related processes for reviewing child deaths. These are:

  • A review of all child deaths (from birth up to 18th birthday, excluding stillborn babies and legally planned terminations) in the Derby City and Derbyshire Safeguarding Children Boards (LSCB) area. This review is undertaken by a Panel drawn from key organisations represented on the Derby City and Derbyshire LSCBs;
  • 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 procedure sets a minimum standard for the Derby and Derbyshire Child Death Overview Panel (CDOP) as outlined in Chapter 5 of the Government guidance Working Together to Safeguard Children (2015) for the review of all deaths. If the death is unexpected, please refer to Response to Sudden Unexpected Death in Childhood in Derby City and Derbyshire Protocol (Documents Library, Protocols).

2. Context

LSCB functions in relation to child deaths are set out in Regulation 6 of the Local Safeguarding Children Boards Regulations 2006. In relation to the deaths of any children normally resident in their area LSCBs are responsible for:

  1. Collecting and analysing information about each death with a view to identifying:
    1. Any case giving rise to the need for a review mentioned in Regulation 5(1)(e);
    2. Any matters of concern affecting the safety and welfare of children in the area of the authority; and
    3. Any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area; and
  2. Putting in place procedures for ensuring that there is a co-ordinated response by the authority, their Board partners and other relevant persons to an unexpected death.

Where the LSCB is made aware of the death of a child in their area who would normally be resident in another Local Authority (LA) area, or the death of a child in another LA area who would normally be resident in their area, the Child Death Review (CDR) Co-ordinator will liaise with their colleague in that area to ensure both Panels are notified of the death and to determine which Panel will be best placed to carry out the review of the child's death. For further information please see Section 11, Deaths of Children out of Area.

In all situations the Child Death Review (CDR) Co-ordinator will be responsible for ensuring appropriate communication takes place, and that the Child Death Overview Panel (CDOP) is regularly updated as to circumstances and timescales.

3. Supply of Information about Child Deaths by Registrars

Registrars of Births and Deaths are required by the Children and Young Persons Act 2008 to supply the CDR Co-ordinator with information which they have about the deaths:

  • Of persons aged under 18 in respect of whom they have registered the death; or
  • Of persons in respect of whom the entry of death is corrected and it is believed that person was or may have been under the age of 18 at the time of death.

Registrars must also notify Derby City LSCB and Derbyshire LSCB if they issue a Certificate of 'No Liability to Register' where it appears that the deceased was or may have been under the age of 18 at the time of death.

Registrars are required to send the information to Derby City LSCB and Derbyshire LSCB no later than seven days from the date of registration, the date of making the correction/ update or the date of issuing the Certificate of No Liability as appropriate.

4. Duty and Powers of Coroners to Share Information

The Coroners (Investigations) Regulations 2013 place a duty on Coroners to inform the LSCB, for the area in which the child died or the child's body was found where they decide to conduct an investigation or direct that a post mortem should take place. The Coroner must provide to the LSCB all information held by the Coroner relating to the child's death.

Where the Coroner makes a report to prevent other deaths, a copy must be sent to the LSCB.

On receipt of an initial report of a death of a child, properly interested persons may make a request to the Coroner for information. The CDR Co-ordinator will inform the Coroner of any relevant information in a timely and agreed manner.

5. Definitions

5.1 Definition of an unexpected death of a child

An unexpected death is defined as the death of an infant or child (less than 18 years old) which:

  • Was not anticipated as a significant possibility for example, 24 hours before the death; or
  • Where there was a similarly unexpected collapse or incident leading to or precipitating the events which led to the death.

It is the responsibility of the attending Doctor and the Police to ascertain if the death is unexpected. If the opinion of the Sudden Unexpected Death in Childhood (SUDIC) Doctor is required, they can be contacted, via the CDOP office, Monday - Friday, 9am-5pm, excluding bank holidays, on 01332 623700 ext. 31537. Where professionals are uncertain, the processes for unexpected child deaths should be followed until the available evidence enables a different decision to be made. See Response to Sudden Unexpected Death in Childhood in Derby City and Derbyshire Protocol (Documents Library, Protocols).

5.2 Definition of preventable child deaths

A preventable child death is one where 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, 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. CDOP should also consider what action could be taken at regional or national level.

6. Core Purpose

The CDOP will undertake a review of all deaths of children who are resident within Derby and Derbyshire.

The CDR Co-ordinator will have overall responsibility in ensuring that on receipt of the CDOP Form Notification of Child Death Form, all agencies / professionals who have been identified as having contact with the child or family are sent a CDOP Form B Agency Report Form for completion and timely return.

The CDOP has responsibility for reviewing the deaths of all children, with priority given to those deaths that are both unexpected and unexplained. In all cases the Derby City and Derbyshire LSCB Sudden Unexpected Death in Childhood (SUDIC) Response Process will be followed.

If information emerges which requires the LSCB Chair to request a Serious Case Review (SCR) in relation to the death of a child, the CDOP review process will be halted. The CDR Co-ordinator will maintain close links with the respective agencies and ensure the CDOP Chair is kept informed. Upon completion of the SCR, a summary will be forwarded to the CDR Co-ordinator to be included in discussion at Panel.

7. Membership

The membership of the Child Death Overview Panel (CDOP) will be reviewed on an annual basis. The CDOP is chaired by a senior representative from Public Health from Derby City Council.

There will be a fixed core membership on the CDOP, which is drawn from the key organisations represented on the Derby and Derbyshire LSCBs. The minimum should be senior management representation from:

  • Derbyshire Constabulary;
  • CDR Co-ordinator;
  • Derby City Council People Service – Early Help and Children's Safeguarding;
  • Derbyshire Council CYPS;
  • Derbyshire NHS Healthcare Foundation Trust;
  • Derby Teaching Hospitals Foundation Trust;
  • Chesterfield Royal NHS Trust;
  • NHS Southern Derbyshire CCG;
  • NHS Northern Derbyshire CCG;
  • Derbyshire Community Health Services Foundation Trust; and
  • Derbyshire Public Health.

Other members will be co-opted as and when appropriate, 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. Injury Prevention Specialists, Derbyshire Fire & Rescue Service, Adult Mental Health Services, Child and Adolescent Mental Health Services, Bereavement Services etc.

Derbyshire and Derby City CDOP also have a lay member who regularly attends the CDOP Panel meetings.

8. Frequency of CDOP Meetings

The CDOP will meet monthly for 3 hours to enable the circumstances of each child death to be discussed in a timely manner.

The cases to be discussed at each Panel meeting will be identified following discussions by the CDR Co-ordinator and SUDIC Doctor. This may include identification of themes and patterns.

The CDR Co-ordinator will be responsible for ensuring case material is distributed to Panel members one week in advance to ensure that there is adequate preparation time. Panel members will acknowledge receipt of case material, and inform the CDR Co-ordinator if there are any specific questions that require addressing prior to Panel, in order to allow a decision to be reached.

9. Key Functions

The Child Death Overview Panel will:

  • Meet regularly to complete a multi-agency evaluation of all child deaths in their area;
  • Ensure that the CDR Co-ordinator has oversight on behalf of the Derby City and Derbyshire LSCBs regarding notification of deaths, monitoring response, information sharing, meetings, case discussions and classification and data collection and reports any areas of concern to Derby City and Derbyshire LSCBs;
  • Where appropriate undertake a detailed and in-depth evaluation into specific cases, including all unexpected deaths, assessing all relevant social, environmental, health and cultural aspects, or systemic or structural factors of the death, along with the appropriateness of the professionals' responses to the death and involvement before the death, in order to complete a thorough consideration of whether and how such deaths might be prevented in future;
  • Collect and collate information using the locally agreed templates (DCSF, 2008) and where relevant seek further information from professionals and family members;
  • Identify local lessons and issues of concern, requiring effective inter-agency working;
  • Identify and report any local Public Health issues and consider, with the Director(s) of Public Health and other provider services, how best to address these and their implications for both the provision of services and for training;
  • Identify and advocate need for changes in legislation, policy and practices, or public awareness, to promote child health and safety and to prevent child deaths;
  • Ensure concerns of a criminal or child protection nature are shared with the Police, Children's Social Care and the Coroner;
  • Ensure any case identified as meeting criteria for a Serious Case Review are referred to the Chair of the LSCB;
  • Provide information to professionals involved with families so that this can be passed on in a sensitive and timely manner;
  • Implement, review and monitor the local procedures for rapid response arrangements in line with Working Together to Safeguard Children, 2015;
  • Monitor the quality of information, support and assessment services to families of children who have died;
  • Co-operate with any regional and national initiatives in order to identify lessons on the prevention of child deaths.

10. Notification of Child Deaths

The CDOP co-ordinator will be informed of all child deaths (expected and unexpected) in the Derby City and Derbyshire LSCBs area, regardless of whether the child is resident in the area. Notification can be received from any professional or agency that becomes aware that a child has died. Notifications should be made by telephoning the CDOP office on 01332 623700 ext. 31537 (Monday - Friday 9am - 5pm, excluding bank holidays).

Notification should be given to the CDR Co-ordinator within 24 hours or on the next working day. In addition to standard notification protocols a CDOP Form A will need to be completed and forwarded to the CDOP coordinator.

The CDOP coordinator will inform Health, Local Authority Children's Social Care and Police and, where relevant, HM Coroner. Further information will be collated by the CDR Co-ordinator who will contact agencies to complete and return CDOP Form B, Agency Report Forms. A Summary Report (CDOP Form C Analysis Proforma) will be forwarded to the CDOP Panel for discussion, coordinated by the CDR Co-ordinator and SUDIC Doctor. Ongoing support to the family will be assessed, managed and reviewed throughout the process.

For deaths of children aged 28 days and under, information from the Perinatal Mortality Review (PMR) meetings will be shared with CDOP and, where appropriate, CDOP B forms will also be requested for completion by professionals.

If the child was known to have a life limiting condition there should be prompt communication with the palliative care team to ascertain that the death was indeed expected.

10.1 CDOP Documentation Process for Expected Death

Following notification of the expected death of a child the CDOP coordinator will request completion of CDOP Form A. This is to be returned to the CDOP coordinator within an agreed time frame.

The CDR Co-ordinator will then request additional information from relevant agencies. A request for information will be sent within 1-2 working days.

CDOP Form Bs are returned completed with as much information as possible. We normally expect these to be returned within 2-4 months, but may take longer where notes have been archived or a post mortem is due.

If agencies do not return required forms to the CDR Co-ordinator this will need to be raised with the CDOP Chair. Persistent failure to provide information will be highlighted to the CDOP Chair and raised with the LSCB.

11. Deaths of Children Out of Area

Where a child who normally lives in the Derby City and Derbyshire area dies outside the Derby City and Derbyshire boundary, it is expected that the CDOP coordinator for the area in which the child died will inform the Derby City and Derbyshire CDOP administrator of the child's death and the circumstances.

Information sharing between the two CDOP's when a child dies out of their normal residency area is in addition to informing HM Coroner within 1 working day.

The CDR Co-ordinator is responsible for ensuring that this process operates effectively.

In respect of a child who dies in hospital, if the death is felt to be expected the death should 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. If the CDOP coordinator is informed of a child's death abroad a discussion will take place between the SUDIC Doctor, CDR Co-ordinator and CDOP Chair to discuss and agree how this death will be reviewed.

Information within CDOP Panel meetings will be anonymised.

Standard data collection does not require parental consent for this information to be passed to the CDR Co-ordinator/SUDIC Doctor. 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, 2015.

If further information is required by accessing additional family records to inform the review, then the person(s) with parental responsibility (Children Act 1989) 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. The family will be offered a CDOP leaflet to assist parents and others with parental responsibility in understanding the review process and how they can contribute. This may be given to the family whilst they are in the Emergency Department (A&E) or normally sent to the family by the CDOP coordinator.

The Derby and Derbyshire Safeguarding Children Boards' Information Sharing Agreement and Guidance for Practitioners (see Documents Library, Guidance Documents) has been developed to ensure professionals are aware of information sharing requirements to enable the LSCB to carry out its statutory duty.

Members of the CDOP must agree to a confidentiality agreement, including sharing and securely storing information when they join the CDOP Panel. This confidentiality agreement will be reviewed at each meeting.

In no case will any Panel member disclose any information regarding Panel discussions 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, but must be agreed with the CDOP Chair in advance. Following all meetings Panel members return all identifiable paper work to the CDOP coordinator.

13. Family and Professional Support

Before the CDOP meets, the CDR Co-ordinator should ensure that explanatory information has been sent to the child's family. Parents and family members should be informed that their child's death will be reviewed, and often have significant information and questions to contribute to the review process.

Parents should be informed that:

  • All cases will be anonymised prior to discussion at Panel;
  • Information gathered will be stored securely and only anonymised data will be collated at a regional or national level;
  • CDOP will make recommendations and report on the lessons learned to Derby City and Derbyshire LSCB's;
  • The LSCB will produce any annual report which is a public document, but it will not contain any personal information that could identify an individual child or their family.

Parents and family members should be assured that the objective of the child death review process is to learn lessons in order to improve the health, safety and wellbeing of children and ultimately, hopefully, to prevent further such child deaths. The process is not about culpability or blame. CDOP should ensure that whenever necessary, arrangements are made for the family to have the opportunity to meet with relevant professionals, for example a professional known to the family before their child died a Paediatrician or a Police officer to help answer their questions.

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. If requested by the family a meeting will be arranged with the CDOP Chair or CDR Co-ordinator to meet with them to offer appropriate and sensitive feedback.

It is important to recognise the emotional impact on staff involved with families where a child has died. All staff should have access to appropriate support within their own agencies.

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

14. Learning from Child Deaths

  • The CDOP should monitor and advise the Derby City and Derbyshire LSCB's on the resources and training required locally to ensure an effective inter-agency response to child deaths;
  • The CDR Co-ordinator will maintain an audit trail of all recommendations made and actions undertaken;
  • The CDOP should 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 should contribute to regional and national initiatives to identify lessons on the prevention of unexpected child deaths e.g. Department for Education;
  • At agreed timescales the CDR Co-ordinator will facilitate study days to allow for update on the CDOP process and overview of lessons learnt;
  • Youth Offending Teams (YOTs) are required 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 CDOP.

15. Reporting Mechanisms

CDOP is a sub-committee of the Derby City and Derbyshire LSCB's and therefore required to submit an annual report to the Derby City and Derbyshire LSCBs.

This information should in turn inform Derby City and Derbyshire LSCB annual reports. It should include the total numbers of deaths reviewed, recommendations made by the Panel about required future actions to prevent child deaths, and any further description of the deaths that the Panel deems appropriate. It should also include a review of actions taken to implement the recommendations from the previous year's report, and set out any such recommendations which have not yet been fully implemented which are to be carried forward. Appropriate care should be taken to ensure confidentiality of personal information and sensitivity to the bereaved families. Information which could lead to the identification of individual children or family members should not be included in the annual report.

CDOP will also contribute to the Directors of Public Health annual report facilitated by the CDOP Chair.

The LSCB 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 and that there is close liaison with The Children's Trusts;
  • Ensuring recommendations are acted upon to improve policy, professional practice and inter-agency working to safeguard and promote the welfare of children; and
  • 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.