Child Death Review Report : Scottish Government Child Death Review Working Group

Appendix 6: Child Death Overview Panels (CDOP) in England

Overview of "Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, March 2013" ¹⁶.

1. CDOPs became a statutory function in April 2008 because of Section 13 of the Children Act 2004 in England required each local authority to establish a Local Safeguarding Children Board (LSCB) for their area. The Act specified the organisations and individuals which should be represented on LSCBs. A LSCB is responsible for developing, monitoring and reviewing child protection policy and procedures, practice issues and making sure training is available to everyone working with children. This includes ensuring that a review of each death of a child normally resident in the LSCB's area is undertaken by a Child Death Overview Panel (CDOP).

2. The objective of the child death review process is not to allocate blame, but to learn lessons and therefore help to prevent further such child deaths (if the death contained preventable factors). The responsibility for determining the cause of death rests with the coroner or the doctor who signs the medical certificate of the cause of death. It is not the responsibility of the CDOP.

3. The LSCB is responsible for ensuring that a review of each death of a child normally resident in the LSCB's area is undertaken by a CDOP. This remains the case if a child has been in contact with organisations from more than one LSCB area prior to their death (although these other organisations should cooperate in undertaking the review). For looked after children, the LSCB of the Local Authority looking after the child will take the lead for conducting the child death review. The LSCB should also ensure they use other avenues such as the media to find out when a child normally resident in their area dies abroad.

4. The CDOP fixed core membership will be made up of those from the organisations represented on the LSCB. There is flexibility to co-opt other professionals for certain types of death when relevant. There should be a Public Health and Child Health professional on the CDOP and the chair should be the LSCB Chair's representative. The chair should not be involved directly in providing services to children and families in the area.

5. One or more LSCBs can choose to share a CDOP. CDOPs responsible for reviewing deaths from larger populations are better able to identify significant recurrent contributory factors.

6. The functions of the CDOP include:

• "reviewing all child deaths up to the age of 18, 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 a Serious Case Review 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."¹⁶