CDOP

12.0 PURPOSE
12.01 COMPLIANCE
12.02 MEMBERSHIP
12.03 FUNCTIONS OF THE CDOP
12.04 NOTIFICATION
12.05 PREPARATION FOR THE CHILD DEATH OVERVIEW PANEL
12.06 CHILD DEATH OVERVIEW PANEL
12.07 LEGAL CONSIDERATIONS
12.08 CATEGORISING DEATH
12.09 IN-DEPTH REVIEWS
12.10 ACCOUNTABILITY AND REPORTING LESSONS LEARNED
12.11 CONFIDENTIALITY AND INFORMATION SHARING

 

 

12.01 Purpose

12.1.1. The Child Death Overview Panel (CDOP) will review the deaths of any children normally resident in North Yorkshire and the City of York with the purpose of collecting and analysing information about each death with a view to identifying any:

• Case giving rise to the need for a Serious Case Review
• Matters of concern affecting the safety and welfare of children in the area of the Authorities and
• Wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area;
• Monitoring the implementation of the coordinated response by the authorities, their Board partners, and other relevant persons to an unexpected death.
  

12.02 Compliance

12.2.1. The CDOP is convened under the authority of the North Yorkshire and City of York Safeguarding Children Boards, and it is expected that all agencies will comply with any reasonable requests made by the panel, including sharing information or in the taking of recommended actions to prevent future/further child deaths.

12.03 Membership

• Public Health Consultant (Chair)
• Safeguarding Children Board Managers, North Yorkshire and York ()
• Designated Doctor (Child Deaths)
• Designated Doctor (Child Protection)
• Designated Nurse (Child Protection)
• Social Care
• Police
• Education
• Coroner or representative
• Fire Service
• Members co-opted as appropriate dependent on nature of review e.g. Highways

12.3.1. Additionally, the CDOP may request the attendance of any person who may provide specialist expertise or otherwise inform the work of the Panel.

12.04.Functions of the CDOP

12.4.1. Implementing, in consultation with the local Coroner, local procedures and protocols that are in line with this guidance on enquiring into unexpected deaths, and evaluating these together with information about all deaths in childhood;

12.4.2. Collecting and collating an agreed minimum data set and, where relevant, seeking information from professionals and family members;

12.4.3. Meeting regularly to evaluate the routinely collected data on the deaths of all children within North Yorkshire & York, and thereby identifying lessons to be learnt or issues of concern, with a particular focus on effective inter-agency working to safeguard and promote the welfare of children;

12.4.4. Having a mechanism to evaluate specific cases in depth, where necessary, at subsequent meetings;

12.4.5. Monitoring the local response to unexpected child deaths including reviewing the reports produced by the rapid response team on each unexpected death of a child and making a full record of this discussion and, where appropriate, providing professionals with feedback on their work;

12.4.6. Referring to the Chair of the LSCB any deaths where, on evaluating the available information, the Panel considers there may be grounds to undertake further enquiries, investigations or a Serious Case Review, and explore why this had not previously been recognised;

12.4.7. Passing specific new information to the Coroner or other authorities as appropriate;

12.4.8. Providing relevant information 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;

12.4.9. Monitoring the support and assessment services offered to families of children who have died;

12.4.10. Monitoring and advising the LSCB on the resources and training required locally to ensure an effective inter-agency response to child deaths;

12.4.11. Organising and monitoring the collection of data for the nationally agreed minimum data set, and making recommendations (to be approved by LSCBs) for any additional data to be collected locally;

12.4.5. Identifying any public health issues and considering, with the North Yorkshire & York Primary Care Trust Director of Public Health, how best to address these and their implications for both the provision of services and for training; and co-operating with regional and national initiatives – e.g. the Confidential Enquiry into Maternal and Child Health (CEMACH) – to identify lessons on the prevention of unexpected child deaths.

12.06 Notification

12.6.1. All child deaths should be notified to the City of York or the North Yorkshire Safeguarding Children Boards through the Child Death Overview Panel Administrator or Manager by the person certifying death.

12.6.2. Notification should take place within 24 hours of the death.

12.6.3. Notification may be made by phone. In such cases the completion of the notification form will be the responsibility of the CDOP Administrator or Manager.

12.6.4. The Notification of Child Death Form (Appendix A) may also be completed by the notifier and sent by secure fax or e-mail to the CDOP Administrator or Manager. All postal communication should be sent by recorded delivery.

12.6.5. The Designated Doctor for Child Deaths should also be notified.

12.6.6. Notification should be made as below:

Local Safeguarding Children’s Board

CDOP Administrator and Manager Telephone: 01609 535182/536909
Fax: 01609 533293
E Mail: cdop@northyorks.gov.uk
Room 171,
County Hall,
Racecourse Lane,
Northallerton,
DL7 8AE
CDOP Administrator and Manager (Out of hours) c/o Emergency Duty Team. Telephone: 0845 034 9417
Fax: 01904 760196

Designated Doctor for Child Deaths

c/o Kate Ward ( For North Yorkshire),
Airedale General Hospital,
Skipton Road,
Steeton,
Keighley,
Telephone: 01535 652511
E Mail: hilary.seward@anhst.nhs.uk
c/o Robin Ball ( For City of York) York Hospitals NHS Foundation Trust,
Wigginton Road,
York
YO31 8HE
Telephone: 01904 725314
Fax: 01904 726885
E Mail: robin.ball@york.nhs.uk

12.6.7. The following persons should notify the CDOP Administrator, for the purpose of cross checking:

•   Nominated person (A&E) ;
• Investigating Police Officer
• Nominated person coordinating the hospital trust report into Child Death
• Pathologist
• Coroners Officers

12.6.8. Professionals who become aware of a child death are encouraged to contact the CDOP Administrator/Manager and give whatever information they have.

12.6.9. The information required at the time of notification is contained in the Notification of Child Death Form and includes:

• Childs name
• Date of birth
• Address
• Next of Kin
• Childs GP
• School
• Place of death, time and date
• Brief details regarding nature of death

12.6.10. On receipt of an initial notification of a possible child death, CDOP staff will attempt to confirm this information by contacting relevant local agencies who may have been involved. Each relevant agency will be contacted and given the information on the identity of the child, members of the household together will other relevant contacts or family members.

12.6.11. The use of the child’s NHS number as a unique identifier will help minimise the risk of mistaken identity or duplication of notifications.

12.6.12. Having ensured that relevant agencies are aware of the child’s death, the next stage of the process is to ensure that they are involved in the preparation for any local case review meeting to investigate and review the circumstances of the case, any contributory factors and the ongoing support needs of the family, and to contribute to the Child Death Overview Panels’ review.

12.07 Preparation for the Child Death Overview Panel

12.7.1. The CDOP Administrator will forward the Agency Report Form (Appendix B) to all agency representatives to enable all relevant information on the child’s case to be collected and collated to form a case summary. This will be compiled by the CDOP Manager from contributions from individual agencies. This acts as the “input data set” for the Child Death Overview Panel

12.7.2. All representatives from each key agency should complete as much of the Agency Report Form as they are able, drawing on a review of the agency records and discussions with individual practitioners. Some aspects of the form are specific to individual agencies but all should be able to prepare summaries of relevant information available to them.

12.7.3. In addition to the narrative and questionnaire components of the Agency Report Form, a brief summery should be available to include post mortem findings (where one has been conducted) and a full copy of the final post mortem report. For deaths of children in hospital or under the care of a secondary/tertiary team a copy of the final discharge/death summary is required.

12.7.4. Once all agency reports are received, the CDOP Manager will collate the information onto one form. This then forms the case summary and input for the CDOP and will at this point be made anonymous.

12.7.5. Recent changes to the coroner’s rules will facilitate the sharing of information at local case review meetings. Where deaths are subject to coroner’s investigations and/or inquests, coroner’s officers will be invited to attend local case review meetings. The information made available in such cases will provide potentially valuable information to conduct the inquest, which, in most cases, will take place after the case review meeting and before the CDOP that reviews the death.

12.7.6. The summary report from the local case review meeting should in all cases in which the coroner remains involved be copied to the coroner to help inform the inquest.

12.08 Child Death Overview Panel

12.8.1. The CDOP will meet monthly to review individual cases; it will:

•  Identify gaps in information and seek clarification
• Collect and collate data in relation to all child deaths by using the CDOP National Analysis Proforma (Appendix C) and report this to the North Yorkshire and City of York Safeguarding Children Boards on an annual basis
• valuate and classify all child deaths, and undertake in-depth reviews of selected cases.
  

12.09 Legal considerations

12.9.1. Where there is an ongoing criminal investigation, the Crown Prosecution Service should be consulted as to what it is appropriate for the Panel to consider and what actions it might take, in order not to prejudice any criminal proceedings

12.10 Categorising death

12.10.1. The agenda of the CDOP will be guided by the design of the national Analysis Proforma (Appendix C).

• A summary of the case will be agreed, along with any identified or agreed cause of death.
• The CDOP will then consider any relevant factors identified from Agency Reports in each of the following domains, to consider the degree to which factors may have contributed to the death. Factors are:
  • Those intrinsic to the child
  • Parenting capacity
  • The family and environment
  • Service provision
• The CDOP will then categorise each death using a national assessment tool developed for the CDOP process. This will form part of the national core data set and enable analysis of information in relation to different types of death.
• The CDOP must then make a decision on the degree of which each death is considered preventable. These categorisations are to inform any effort to reduce childhood deaths and do not in itself carry any implication of blame on any individual party. It simply acknowledges where factors are identified which, had they been different, may have resulted in the death being prevented.
• Once the assessment has been completed the CDOP must consider if there are any lessons to be learned, recommendations to be made or actions taken in response to the death.

12.10.2. The main public output from the CDOP will be in summary form, drawing from the information from individual cases and from overall pattern of events, contributory factors and service provision in their local area.

12.11 In-Depth Reviews

12.11.1. The Safeguarding Children Boards will undertake or commission in-depth reviews when the assessment identifies issues that classify the case as avoidable or potentially avoidable but do not fit the criteria of a Serious Case Review. Such reviews will also provide the opportunity to make recommendations to other agencies regarding preventative actions that may be required in the future.

12.11.2. In-depth reviews should also be undertaken if patterns emerge in relation to a number of child deaths in order to gain a greater understanding of the issues and to establish any preventative measures that could be put in place.

12.12 Accountability and Reporting Lessons Learned

12.12.1. The Child Death Overview Panel is responsible for developing its work plan, which should be approved by the LSCBs. It will prepare an annual report for the LSCBs, which are responsible for publishing relevant, anonymised information.

12.12.2. Where a trend or pattern of child fatalities is identified, and where it is assessed that action should be taken to avoid further deaths, the CDOP should make recommendations to the LSCB chairs at the earliest opportunity. On receiving the recommendations, the LSCB chair should ensure appropriate action is taken by the respective agencies. However, the making of recommendations to the LSCB should not prevent the taking of any immediate action by individual agencies.

12.12.3. The LSCB takes responsibility for: disseminating the lessons to be learnt to all relevant organisations, ensuring that relevant findings inform the Children and Young People’s Plan, and acting on any recommendations to improve policy, professional practice and inter-agency working to safeguard and promote the welfare of children.

12.12.4. The LSCB will supply data regularly on every child death as required by the Department for Children, Schools and Families to bodies commissioned by the Department to undertake and publish nationally comparable, anonymised analyses of these deaths.

12.13 Confidentiality and Information Sharing

12.13.1. Information discussed at the CDOP meetings will be anonymised prior to the meeting.

12.13.2. It is essential that all members adhere to strict guidelines on confidentiality and information sharing. Information is being shared in the public interest for the purposes set out in Working Together to Safeguard Children 2006, and is bound by legislation on data protection.