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7.2.1 Child Death Overview Panel


  1. Purpose and Practice
  2. Core Functions of CDOP
  3. Procedures for Notifying a Child Death
  4. Informing Parents or Carers
  5. The Child Death Overview Panel Meetings

1. Purpose and Practice

One of the HSCP functions in relation to the deaths of any children in its area is to:

  • Collate and analyse information about each death with a view to identifying any case that requires a serious case review;
  • Any matters of concern affecting the safety and welfare of children in the area; and
  • Any wider public health or safety concerns arising from a particular death or pattern of deaths.

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

  • Core functions of the Child Death Overview Panel (CDOP);
  • Procedures for notifying a child death.

2. Core Functions of CDOP

The functions of the CDOP include:

  • Reviewing all child deaths from birth to18 years in Hertfordshire 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 LSCP 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 LSCP;
  • Where a suspicion arises that neglect or abuse may have been a factor in the child’s death, referring a case back to the LSCP Chair for consideration of whether an SCR 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.

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. Each CDOP should prepare an annual report of relevant information for the LSCP. This information should in turn inform the LSCP annual report.

Information on child deaths will be gathered by the Hertfordshire Safeguarding Children Partnership (HSCP) Business Unit.

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).

3. Procedures for Notifying a Child Death

Any person notifying the designated person in the HSCP of the death of a child should provide as much detail as is known to them in relation to the child and family and the circumstances of the death. They should inform the designated person of any professionals known to be involved with the child or family.

The agency notified of a child's death will complete Form A -Notification of Child Death. Form As  completed by Children's Services are to be sent to the Child Protection Unit who will send these to the HSCP Business Unit. Individual professionals will notify the HSCP Business Unit at the same time as they notify the Coroner (in the case of an unexpected death) or Registrar/CCG.

The Form A should be sent to the HSCP Business Unit with 24 hours of the child death.

On receiving the Form A the HSCP Business Unit will send out the Form B to the designated contacts at the relevant agencies listed below.

  • Children's Services;
  • Police;
  • Coroner;
  • GP;
  • Child Protection;
  • Rapid Response;
  • Schools and Colleges;
  • Mental Health and Learning Disability Services;
  • Any other agencies involved with the child.

Form B’s will be sent out as soon as possible which must be no later than 3 months after the death. Form B’s must be completed in full and returned to the HSCP Business Unit within three weeks.

If additional information is available this should be attached to Form B. The HSCP Business Unit will enter the information from Form B onto a secure data base and prepare this for review at the Child Death Overview Panel Meetings.

Form As and Bs are held by the notifying agencies and are to be sent securely to the HSCP Business Unit (see below), preferably as an encrypted document sent by email.

4. Informing Parents or Carers

Within one month of the death, the CDOP team will send out a letter and the HSCP leaflet: ‘What we have to do when a child dies’ to  parents or carers of the child informing them that a review will take place and asking them to contribute to the review, should they wish to, via a health professional. A copy of the letter should be sent to the designated health professional at the same time.

5. The Child Death Overview Panel Meetings

Collated Form Bs sent to all panel members.

CDOP Meeting will review each case brought before it 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 LSCP and any other relevant body and the LSCP 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.

HSCP Business Unit Contact Details:

Angela Coster
Room 147
County Hall
Pegs Lane
SG13 8DF
Telephone: 01992 555675
Secure Fax: 01992 588201