Section 14: Child Death Review Processes

Introduction

This guidance sets out the procedures to be followed when a child dies in City of York and North Yorkshire area. They do not replace existing procedures for the investigation of child protection referrals.

There are two interrelated processes for reviewing child deaths (either of which can trigger a Serious Case Review):

1. A rapid response by a group of key professionals who came together for the purpose of enquiring into and evaluating each unexpected death of a child.
2. An overview of all child deaths (under18 years) in the City or York and North Yorkshire areas, undertaken by the joint City of York and North Yorkshire Child Death Overview Panel (CDOP).

Arrangements

This procedure is based on Chapter 7 of Working Together to Safeguard Children (2006). The LSCB regulations mean that child death review processes became compulsory on 1 April 2008.

Ultimately the circumstances of an unexpected death will be examined by HM Coroner, but they may also form the basis of criminal prosecution and other legal proceedings. Any unexpected death of a child is a tragedy for the family members and therefore any enquiries or investigations need to balance forensic and medical requirements with the family's need for support.

A minority of unexpected deaths are the consequence of abuse or neglect, or these are found as associated factors. In all cases, enquiries should seek to understand the reasons for the child's death, address the possible needs of other children in the household, the needs of all family members, and also consider any lessons to be learnt about how best to safeguard and promote children's welfare in the future.

Families should be treated with sensitivity, discretion, and respect at all times, and professionals involved should approach their enquiries with an open mind.

Definition of unexpected death

An 'unexpected death' is the death of a child ( birth to 18 years, excluding babies still born) which was not anticipated as a significant possibility 24 hours before the death, or where there was a similarly unexpected collapse leading to or precipitating the events that led to the death.

A child who dies with a known disability or medical condition should be responded to in the same manner as any other child.

The Designated Doctor (Child Deaths) should be consulted where professionals are uncertain about whether the death is unexpected. If in doubt, the death should be treated as unexpected and these procedures should be followed until the available evidence enables a different decision to be made.

Responding to the unexpected death of a child: Rapid Response

Rapid Response describes the process of communication, collaborative action, and information sharing following the unexpected death of a child. The purpose of Rapid Response is to ensure that the appropriate agencies are engaged and work together to:

• Respond quickly to the unexpected death of a child;
• Make immediate enquiries into and evaluate the reasons for and circumstances of the death, in agreement with the coroner;
• Undertake the types of enquiries that relate to the current responsibilities of each organisation when a child dies unexpectedly;
• Collate information in a standard format;
• Work together appropriately post death, keeping contact with family members and relevant professionals to ensure that they are appropriately informed.

Rapid Response begins at the point of death and ends with the completed report to the Child Death Overview Panel.

The seven key strands to Rapid Response are (Section 14, Table 1):

• Care of the bereaved family: This includes the welfare and protection of remaining siblings, spiritual needs of the family and where appropriate, involvement of the extended family;
• Deciding upon the response: Deciding on whether the death is unexpected and whether to implement the rapid response procedure;
• Notification to a CDOP: The Child Death Overview Panel will be notified of all child deaths by the attending paediatrician, using the notification form (Section 14, Table 2);
• Child Protection: Emerging information giving rise to child protection concerns about remaining siblings/other children or peer group will require formal notification to Children's Social Care in line with local LSCB procedures;
• Serious Case Review: All agencies must be mindful of any emerging information giving rise for the LSCB to consider conducting a serious case review. The decision to undertake the review will be taken by the Chair of the LSCB where the child normally resides. Serious Case Reviews will operate simultaneously with the rapid response procedure;
• Media issues: There should be a coordinated response to media enquiries, agreed by all relevant agencies (where possible at the case discussions). Where appropriate, media enquiries should be directed to the relevant press office;
• Support to staff: There will be varying degrees of impact upon staff and agencies need to have arrangements in place to manage this.

The investigation and management of unexpected death in childhood must follow a multi-agency approach, maintaining a balance between medical and forensic requirements whilst taking account of the needs of the family.

All cases of unexpected death in childhood must be referred to the coroner.

Immediate response to the unexpected death of a child in the community

If the first professionals on the scene are not medical professionals, then they must obtain urgent medical assistance as the first priority.

Death should not be assumed and therefore the first immediate response should be:

• Initiate immediate resuscitation unless clearly inappropriate. Resuscitation once commenced should be continued according to the UK Resuscitation Guidelines (2005);
• The child should be transferred to the nearest Accident and Emergency (A&E) Department by ambulance, unless there is instruction not to do so by the police and resuscitation has not been initiated. In such cases the child will be taken to the hospital mortuary.
• Prior to arrival at A&E, provide relevant information and history to the A&E staff;
• Notify the Police if they are not already present.

Where the child is not taken immediately to the A&E, the professional confirming the fact of death should inform the Designated Doctor (Child Deaths) at the same time as the Coroner is informed.

The first professional on the scene must note the position of the child, the clothing worn, and circumstances in which the child was found.

Role of the Police at the Scene: Guidance

The provision of medical assistance to the child is obviously the first priority. If an ambulance is not present ensure one is called immediately, and consider attempting to revive the child unless it is absolutely clear that the child is dead. Ensure that the officer in charge of the investigation is informed of any resuscitation attempts so they can inform the pathologist.

As at any incident, police officers must be aware of potential risks to health. These could include risk factors present at the scene but not obvious which could have contributed to the child's death and may endanger attending emergency services. For example there could be a carbon monoxide build up, faulty electrical appliances or the presence of chemicals. Each case must be assessed on its merits and appropriate expert advice taken prior to the officers approaching the body.

Normally the first officer attending the scene will be responding to an emergency call relating to a child's death. This officer will assume control of the situation and ensure the following actions take place:

• If the child is dead preserve the body and location as a crime or road traffic collision scene;
• Establish suitable cordons and limit access to the scene - Initiate a scene log;
• Attendance at the body by medics should be via a common approach path;
• Contact Control Room and request a supervisor is informed and attends - A decision will then be made about which specialist resource will attend;
• In Road Traffic Collisions the duty Traffic SIO (Senior Investigating Officer) must be informed (normally of Sergeant rank). In the case of all other unexplained or suspicious deaths the duty Detective Inspector must attend the scene. If out of office hours the on call crime Senior Investigating Officer must be contacted - In cases of unexplained or suspicious child death the relevant duty SIO (crime or traffic) will ultimately decide on who has access to the scene and in consultation with the Coroner when the body will be removed.
• The preservation of the scene and the level and type of investigation will be relevant and appropriate to the presenting factors.
• The investigation of any suspicious or unexplained child death should follow the guidance in the ACPO Murder Investigation and ACPO Road Death Investigation Manuals, and the NPIA Core Investigative Doctrine.
• Scene preservation and examination should follow the established techniques in those manuals.

There are a number of additional factors to consider with a child's death:

• Retain items such as the child's used bottles, cups, food or medication;
• The child's nappy and clothing should remain on the child but arrangements should be made for them to be retained at the hospital. If the nappy has already been removed from the baby prior to police arrival ensure that it is recovered from the parents and handed to the police - The nappy or clothing may be required for future laboratory examination. Any other clothing should only be retained if it is of evidential value;
• If it is necessary to remove items from the house, do so with consideration for the parents. Explain that it may help to find out why their child has died. Ask the parents if they want the items returned;
• Records of monitoring equipment from the Ambulance Service may be of evidential value and should be secured and preserved as this information may only be retained for 24 hours;
• In cases of suspicious death the family will not be allowed access to the scene without the approval of the SIO. In all other cases the SIO must be consulted prior to the family being allowed access or continued access to any scene.

The above is NOT an exhaustive list of considerations and should be treated only as a guide.

Do record any environmental features that may have contributed to the child's death. Additionally record any evidence that indicates or could have contributed to the death such as temperature of scene, condition of accommodation, general hygiene and the availability of food/drink. Consider faulty appliances that may have caused the child's death.

Parents are likely to want to hold and touch the body of their loved one. Whilst fully understandable these wishes must be balanced against any potential forensic contamination. Most times this should be allowed, but only after consultation with the officer in charge of the investigation, and then only under supervision. 

Offer to contact friends or relatives who might support parents, and employers to explain absence.

Ultimately the purpose of any police investigation is to fully establish the circumstances leading to the child's death in order to assist the Coroner and / or the Crown Court.

The role of the GP: Guidance

There are times when a GP is called to the child first. In such circumstances the GP should adhere to the same general principles as the ambulance staff.

It is essential for the GP to contact the police or Coroner's officer if they are the first on the scene, after taking into account their primary responsibility of saving life or declaring death. The best route is the Police Call Centre.

A GP may not issue the death certificate in these circumstances. Children who have died without explanation should be seen in the A&E Department by a paediatrician and not sent directly to the mortuary. This enables the clinical history, examination and any initial investigations to be completed and information given to parents.

Moving a child to the hospital or mortuary

In all cases where the body is taken directly to a hospital or a mortuary, arrangements must be made for a consultant paediatrician to be informed of the child's death, in order that an examination of the body can be made, tests arranged and medical information collated.

If the parents/carers wish to accompany the child's body from the home to the mortuary, then this should be facilitated, unless the death is viewed as unnatural. In all cases the body should be transported to the hospital either by paramedics or undertakers as appropriate.

Phase One of Rapid Response: Immediate response to the unexpected death of a child taken to a hospital

On arrival the child should be taken to the appropriate resuscitation area and the emergency crash paediatric procedure should be initiated.

The child must immediately be assessed by a senior paediatrician and death confirmed or appropriate resuscitation started; unless it is clear that the child has been dead for sometime resuscitation should always be initiated.

A qualified nurse must be allocated to look after the attending family and stay with the family, keeping them informed about what is happening. The identity of the people accompanying the child and their relationship to the child must be clarified by this nurse and recorded.

A detailed history should be taken during resuscitation by the Paediatrician, and as appropriate afterwards. Information must include a full medical history, a family history, history of any other child deaths, previous incidents of concern and an account of what happened and who was present. The history should be made available to the police.

When the child has been pronounced dead the Consultant Paediatrician should inform the parents/carers in attendance, having first reviewed all of the information available at that time.

The responsibility for further management and support of the family will usually rest with the Unexpected Death in Childhood Paediatrician (UDIC Paediatrician) in conjunction with the police, social care, and other primary health care teams.

The UDIC Paediatrician will collect all hospital records, including A&E sheets, for the child and other siblings in the family and make them available to the police for any subsequent post mortem and enquiries.

The UDIC Paediatrician will start off the process of notifying agencies that the child has died. They will contact the CDOP Administrator as well as alerting key health and social care staff.

At this stage and until there has been a multi agency Rapid Response meeting, the police press office will manage all media requests.

Assessment and investigation once the child has arrived at the A&E Department

As soon as possible after the arrival of the child at the A&E Department, the senior nurse on duty must ensure that the police have been contacted. The senior nurse on duty will also contact Customer Relations/Advice or EDT (if out of office hours) who should be asked to check records held by social care, including whether the child or siblings of the child are subject to a Child Protection Plan.  A ContactPoint check is also required as the child may have a lead professional.

Actions to be undertaken at the hospital: Guidance

• The Consultant Paediatrician should examine the child. Any injury or superficial lesion should be documented on a body chart.
• The family should be informed that the death must be notified to the coroner and that a post mortem will be required.
• Core body temperature should be taken immediately on presentation, using a low temperature thermometer if necessary.
• The site and route of any intervention in resuscitation needs to be carefully recorded.
• The full growth measurement for all children and young people who have died should be plotted on a centile chart.
• Some laboratory specimens may be taken during resuscitation, according to clinical need. In the case of SUDI there is a nationally agreed schedule of samples to be taken.
• Details of samples should be clearly documented and the site of investigation should be recorded in the notes.
• Further investigation such as skeletal survey will be done according to the coroner's wishes.
• Intravenous and intra-arterial lines should not be removed unless agreed by the SIO. If any lines have been removed they should be retained as potential exhibits and their existence made aware to the police.
• If an endotracheal tube has been inserted this should also be removed after its correct placement in the trachea has been confirmed by direct laryngoscopy (preferably by someone other than the person who inserted it). Again this should be retained as an exhibit if already removed.
• Photographs of the child, prints of the hand and foot and a small lock of hair, as mementoes for the family, can be obtained following post mortem in most cases. As these samples are not taken before the post mortem, any wishes expressed by the family should be recorded.
• Clothing must be left on the child. If removed to allow examination it should be placed in labelled specimen bags. Other items such as bedding brought in with the child should be placed in labelled specimen bags to be given to the Senior Investigating Officer. No items should be returned to the parents without consultation with the Senior Investigating Police Officer involved.

Before the family leave the A&E Department the Consultant Paediatrician on-call should see them together with the police SIO. In certain cases the police may wish to deploy a Family Liaison Officer who has a particular investigative role to perform. Wherever possible the UDIC Paediatrician should also be present for this initial joint interview with the parents.

Written information, such as leaflets published by the Foundation for the Study of Infant Deaths, should be given to the parents at this time.

Review of the history and circumstances of the death by the police SIO, consultant paediatrician on-call and, where possible, the UDIC paediatrician should take place. Any child protection concerns for other children in the household must be discussed. If significant concerns emerge, this discussion will become the initial multi-agency strategy discussion under the Child Protection Section 47 Procedures.

Sudden unexpected death process

The Initial Home Visit

The police SIO and UDIC paediatrician should make a decision about whether to visit the home or the site of the child's collapse or death. This should always take place for infants who die unexpectedly.

They will decide if any other health care professional should be asked to attend, for example the GP, midwife, or health visitor. It is noted that the role this health professional took with the bereaved family in the pilot schemes was invaluable. This is usually the first time the family have returned to the scene and for some it may be the only time. If a Family Liaison Officer has been deployed by this stage they should attend.

The police and UDIC paediatrician should consider in detail the events leading to the infant's death along with the systematic examination of the site of the child's collapse/death.

The paediatrician's role is to help to identify, understand and investigate factors that may have contributed to a natural, accidental or non accidental cause of death and ensure that the pathologist is fully informed before starting the post mortem examination.

After the home visit the police, UDIC paediatrician and any other professional who visited should review any significant concerns with regard to possible neglect or abuse having contributed to the child's death.

It is important to make detailed records of the history and examination findings, which must be dated and signed. As far as possible accounts should be recorded using the parent's/carer's own words.

Post Mortem, pathologist and Coroner

If there are no suspicious circumstances, after an evaluation of initial information; from the ambulance service, hospital and previous records, primary care, police and social care records – the post-mortem should be conducted by a pathologist with special expertise in paediatric pathology. If possible the post-mortem should be completed within 48 hours of the infant's death. If during the post-mortem the pathologist becomes concerned that there may be suspicious circumstances, they must halt the post-mortem and inform the Coroner.

If the Coroner has any concerns that the death may be suspicious, then a Home Office pathologist will be used in conjunction with a paediatric pathologist. Where a pathologist is qualified both as a forensic and paediatric pathologist they may complete the post-mortem on their own.

Both the Coroner and the pathologist must be provided with a full history at the earliest possible stage. This will include a full medical history from the paediatrician, any relevant background information concerning the child and the family and any concerns raised by any agency. The police SIO is responsible for ensuring that this is done. A pro-forma is available for the paediatrician. The medical notes will also usually be sent/taken to the pathologist by the police officer attending the post-mortem. Depending on the circumstances of death this could be one of the investigating officers or the Coroner's Officer. Due to short timescales it is imperative all relevant information has been collected by the Paediatrician/ Nominated Nurse and handed to the police to take to the post mortem.

The Coroner's Officer should inform all relevant professionals of the time and place of the post-mortem, including the SIO and consultant paediatrician. The family should also be informed (via the FLO if one has been deployed).

The SIO should attend the post-mortem. If this is not possible, then he/she must send a representative who is aware of all of the facts of the case. In cases involving a Home Office Pathologist the SIO will decide appropriate resources to attend in line with the ACPO Murder Manual. As a minimum this would normally involve a CSI (Crime Scene Investigator), CSM (Crime Scene Manager) and exhibits officer. In all other cases the police will decide on the appropriate resources to attend.

The Pathologist at post-mortem will arrange a number of investigations.

If the paediatrician has arranged any medical investigations before or after death, the pathologist and Coroner must be informed and the results forwarded.

All professionals must endeavour to conclude their investigations expeditiously. This should include the post-mortem results such as histology. The release of the child's body is a matter for the Coroner in consultation with the SIO.

The interim or final findings of the post-mortem should be provided immediately after the post-mortem examination is completed and the Coroner updated. The interim result may well be 'awaiting histology/virology/toxicology'.

The police/Coroner's Officer will prepare a report for the Coroner once all information relevant to the investigation (including the pathologist's report) has been gathered. This report is intended to form the basis of a Coroner's inquest. The target timescale for the completion of this report is two weeks after the conclusion of the investigation.

When a child dies away from North Yorkshire and York

When a child who is normally resident in the North Yorkshire and York area dies out of their home area, the area in which the child dies will follow the process detailed in the relevant Local Safeguarding Children Board procedure.

All such deaths must be notified to the North Yorkshire and York Child Death Review Panel Administrator as soon as possible after the child has been confirmed dead.

When a child living out of county is brought to a local hospital

When a child who lives out of the county dies in the area or where their body is brought to a local hospital (for example where they live just outside of the county), the North Yorkshire and York notification procedure will be followed. The designated doctor for child death should contact their counterpart in the area in which the child is resident and send notification to the LSCB for that area. 

The LSCB managers for the two areas will decide which CDOP will review the child's death on a case-by-case basis. As a minimum the hospital paediatricians receiving the child will be required to provide a report the LSCB, which will be forwarded to the LSCB of the area where the child was resident.

Phase Two Rapid Response (Within 5-7 days) The Initial Case Discussion

In all cases a case discussion will take place following the preliminary results of the post-mortem examination. This will be arranged by the Designated Paediatrician for unexpected deaths in childhood and will involve the police, the pathologist, and any other relevant professionals. In many cases the discussion can be held by phone. Where a meeting is necessary, all health, and social care professionals and relevant professionals from other agencies should be invited to attend.

The purpose is to ensure all agencies are informed and updated, that all are working together and should information give rise to safeguarding issues, the appropriate procedure is implemented.

Phase Three Rapid Response (Within 8-12 weeks) The Multi-Agency Case Discussion Meeting

Once the results of all relevant investigations have been obtained, a multi-agency case discussion meeting is to be held. The meeting is convened and chaired by the UDIC Paediatrician or Designated Doctor and is formally recorded.

The purpose of the meeting is to:

• Share information to identify the cause of death;
• Identify those factors that may have contributed to the death;
• Plan future care for the family;
• Identify potential lessons to be learnt;
• Inform the Coroner's inquest.

In cases of suspicious death the amount of information released from the police investigation to this meeting will be sufficient to inform on the above issues (it must be recognised there will be occasions where information cannot be disclosed due to ongoing investigative concerns).

This meeting should involve the G.P., health visitor/school nurse/midwife, paediatrician, other relevant health professionals involved with the family, pathologist, senior investigating police officer, coroner's officer, social care manager, head teacher and any other relevant professionals.

The meeting should always consider the possibility of abuse or neglect. If no evidence is identified to suggest abuse or neglect as contributory factors this should be documented as part of the report of the meeting. The following should also be documented:

• Any issues arising from the medical and social care given to the child and family;
• Shortcomings in the medical and social care given to the child and family that may be identified;
• Appropriate measures to improve future care;
• Any issues of good practice.

After the case discussion meeting the UDIC Paediatrician, in consultation with the pathologist and coroner, should write a detailed report on the available information concerning the child's death. The CDOP report form should be completed recording issues from this meeting.

Arrangements should be made for the UDIC paediatrician and the GP or health visitor/school nurse/midwife to jointly see the parents to explain the content of this report and to address any further questions.

The meeting minutes should be sent to each of the agencies involved with a copy to the Coroner and the Child Death Overview Panel.

 The completed Child Death Agency Report should be forwarded to the Child Death Overview Panel.

The Child Death Overview Panel (CDOP) will undertake an overview of all deaths of children normally resident within North Yorkshire and the City of York. This will be a paper exercise based on the information available from those who were involved in the care of the child, before and immediately after the death. 

Section 14, Table 1: Seven strands of Rapid Response to be considered.

Child dies, notify LSCB of all deaths

Section 14: The Child Death Overview Panel

Purpose

The Child Death Overview Panel (CDOP) reviews the deaths of all children and young people normally resident in North Yorkshire and the City of York. Its purpose is to collect and analyse 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;
• 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 Rapid Response to the unexpected death by the different agencies.

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 taking recommended actions to prevent future/further child deaths.

Membership

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

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

Functions of the CDOP

The functions of CDOP are to:

• Implement, in consultation with the local Coroner, procedures and protocols that are in line with national guidance on enquiring into unexpected deaths, and evaluate these together with information about all deaths in childhood;
• Collect and collate an agreed minimum data set and, where relevant, seek information from professionals and family members;
• Meet regularly to evaluate the routinely collected data on the deaths of all children within North Yorkshire & York, to identify 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;
• Evaluate specific cases in depth, where necessary, at subsequent meetings;
• Monitor the response to unexpected child deaths including reports produced by the rapid response team and, where appropriate, provide professionals with feedback;
• Refer to the Chair of the LSCB any deaths where 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;
• Pass specific new information to the Coroner or other authorities as appropriate;
• Provide 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;
• Monitor the support and assessment services offered to families of children who have died;
• Monitor and advise the LSCB on the resources and training required locally to ensure an effective inter-agency response to child deaths;
• Organise and monitor the collection of data for the nationally agreed minimum data set, and make recommendations (to be approved by LSCBs) for any additional data to be collected locally;
• Identify any public health issues and consider, with the North Yorkshire & York Primary Care Trust Director of Public Health, how best to address these; and co-operate 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.

Documentation

The DCSF have provided Panels with a series of templates to collect information about children's deaths. These templates may be found on the Every Child Matters website (www.ecm.gov.uk/childdeaths). The notification form is also available on the websites of the North Yorkshire and York Safeguarding Children Boards.

Notification

All child deaths should be notified to the LSCB in the area in which the child died. Where the child dies in North Yorkshire or York, then referral should be to the CDOP Manager/ Administrator at the address in Appendix 2, regardless of the home address of the child. Where a child resident in North Yorkshire or York dies out of the area, then the LSCB for that area should be notified.

Notification should take place within 24 hours of the death and should be made by the person certifying death. Coroners' Officers will also notify the CDOP Team for those deaths they are informed of.

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

The Notification of Child Death Form can be found on the NYSCB website. It may be completed by the referrer and sent by secure fax or e mail to the CDOP Administrator or Manager. All postal communication should be sent by recorded delivery.

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. The Designated Doctor for Child Deaths should also be notified. Contact details may be found in LSCB Procedures, Appendix 2.

The information required at the time of notification includes:

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

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.

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

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 Panel's review.

Preparation for the Child Death Overview Panel

The CDOP Administrator will forward the Agency Report Form (part of the DCSF set of templates) 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.

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.

In addition to the narrative and questionnaire components of the Agency Report Form, a brief summary 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.

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.

Recent changes to the coroner's rules 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.

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.

The Child Death Overview Panel

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 and report this to the North Yorkshire and City of York Safeguarding Children Boards on an annual basis;
• Evaluate and classify all child deaths, and undertake in-depth reviews of selected cases.

Legal Considerations

Where there is an ongoing criminal investigation or prosecution, the Police 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.

Categorising Death

The agenda of the CDOP is guided by the design of the national Analysis Proforma. It will involve:

• A summary of the case prepared by the CDOP Manager along with the agreed cause of death.
• The panel will then consider any relevant factors identified from agency reports in each of the following domains;
  • Those intrinsic to the child;
  • Parenting capacity;
  • The family and environment;
  • Service provision

The panel will consider the degree to which factors in each of these domains may have contributed to the death.

• 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 will also make a decision on the degree to which each death is considered preventable. This categorisation is to inform any effort to reduce childhood deaths and does 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 panel will consider if there are any lessons to be learned, recommendations to be made or actions taken in response to the death.

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.

In Depth Reviews

The Safeguarding Children Boards may undertake or commissions 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 provide the opportunity to make recommendations to other agencies regarding preventative actions that may be required in the future.

In-depth reviews will 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.

Accountability and reporting lessons learned

The Child Death Overview Panel is responsible for developing a 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.

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 will make recommendations to the LSCB chairs at the earliest opportunity. On receiving the recommendations, the LSCB chairs 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.

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;
•  Acting on any recommendations to improve policy, professional practice and inter-agency working to safeguard and promote the welfare of children.

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.

Confidentiality and information sharing

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

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.

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