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9.2 Reviewing All Childhood Deaths

See: Working Together to Safeguard Children.


This chapter was comprehensively amended throughout in September 2016.


  1. Introduction
  2. Procedure

1. Introduction

Working Together to Safeguard Children introduced new responsibilities for Safeguarding Children Boards in relation to the review of all deaths in children under 18. This has now been amended by Working Together to Safeguard Children, which contains clarification on the responsibilities of LSCB's and greater detail regarding the role and functions of the Child Death Overview Panel (CDOP) in terms of notification, monitoring response, information sharing, meetings, case discussions and classification and data collection.

This chapter complements a separate chapter, Investigation of all Unexpected Deaths in Childhood Procedure.

The purpose of the review process is to gain an understanding of the circumstances of the child's life and death, including the possibility of abuse or neglect (and thus providing a safety net to identify possible Serious Case Reviews). One output will be the learning of common lessons and themes which will be useful in the formulation of Public Health strategies.

The exercise will largely be paper based but will involve the convening of regular Child Death Overview Panel meetings to discuss each individual case.

Working Together states that the functions of the CDOP include:

  • Reviewing all child deaths, excluding those babies who are stillborn and planned terminations of pregnancy carried out within the law;
  • Collecting and collating information on each child and seeking relevant information from professionals and, where appropriate, family members;
  • Discussing each child's case, and 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;
  • 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 LSCB 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 LSCB;
  • Where a suspicion arises that neglect or abuse may have been a factor in the child's death, referring a case back to the LSCB Chair for consideration of whether an SCR is required;
  • Agreeing local procedures for responding to unexpected deaths of children; 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.

2. Procedure

2.1 General

The Child Death Overview Panel is a sub-group of the Lincolnshire LSCB and is responsible for reviewing all deaths occurring in Lincolnshire.

Cases will be reviewed in a two tier process. For the purposes of rapid learning, cases will be brought to Panel for an initial review whilst other investigations are ongoing. The case will be brought back for a final review once all other processes (e.g. coronial enquiries, legal proceedings etc.) have concluded.

2.2 Notification

Should an agency become aware of a child death, it is their responsibility to notify the designated person for the LSCB in the area in which the child was resident. Where the child was resident in Lincolnshire, the referral must be made to the Lincolnshire CDOP administrator.

Should it not be clear where the child was resident, it is still imperative that you notify the Lincolnshire CDOP Administrator who will ensure the information reaches the right LSCB.

2.3 Data Collection

Following notification of a child's death, the Lincolnshire CDOP administrator will organise the distribution of an agency report to all relevant agencies, as determined by local procedures and the circumstances of the death. The administrator will then collate all the information received in preparation for the Panel.

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 the Coroner decides to conduct an investigation, or directs 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 a Post Mortem examination has taken place, this report must always be obtained. Where the Coroner makes a report to prevent other deaths, a copy must be sent to the LSCB.

2.4 Parental Involvement

Parents will be informed of the role of the CDOP and will be invited to contribute and/or receive feedback.

2.5 Panel Meetings

The frequency of the meetings should reflect the number of child deaths in the LSCB area and for the most part should take place on a monthly basis. Where the number of deaths is low, the Panel meeting can be deferred for up to 3 months (minimum 4 Panel meetings a year).

The frequency should enable the circumstances of all child deaths to be discussed within 6 months of date of notification of death.

The CDOP will have a fixed core membership drawn from organisations represented on the LSCB with flexibility to co-opt other relevant professionals to discuss certain types of death as and when appropriate. It should be chaired by the LSCB Chair's representative and is accountable to the LSCB. That individual should not be involved directly in providing services to children and family in the area.

Panel members will consider the collated agency reports and any other relevant information.

2.6 Report

The work of the CDOP will be presented in the form of an annual report to the LSCB.

2.7 Reviews

Child Death Review arrangements will be reviewed annually.

For further information please see the LSCB website, where the full Lincolnshire CDOP procedure can be viewed.