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

Appendix 7: Report on visit to Merseyside Child Death Overview Panel, July 2013

1. As part of the Child Death Review scoping process, Dr Kate McKay and Dr Marjorie Johnston visited the Merseyside Child Death Overview Panel (MCDOP) team in Liverpool in July 2013. The following is a summary of the findings of that meeting. The meeting was hosted by Irene Wright, CDOP manager for the Liverpool LSCB and Merseyside CDOP. Some of the summary has been supplemented by visiting the Liverpool Local Safeguarding Children Board (LSCB) website.³⁹

2. The details of the CDOP process will vary in every area and there is scope for the process to fit round the needs of that area. For example the frequency of the CDOP meetings and whether LSCBs choose to merge with surrounding areas may depend on the number of deaths occurring in an area. The following describes the process and organisation of the Merseyside CDOP.

History of the Merseyside CDOP

3. Each of the five Merseyside LSCBs set up their own CDOPs which functioned until 2011. In April 2011 four Merseyside CDOPs, Liverpool, St Helens, Sefton and Wirral merged to form the Merseyside CDOP (MCDOP). The fifth is considering joining this larger CDOP.

CDOP process

Background

4. The MCDOP has one CDOP manager. Each separate area within the MCDOP has a part-time administrator with one overall whole time administrative manager.

5. There were 85 deaths reviewed last year. There are monthly panel meetings, reviewing around 6 to 9 deaths each. There is no meeting in August and December to account for staff holidays. As the majority of deaths are neonatal, every third meeting is a neonatal death CDOP (with current plans to make this every second meeting).

Process

6. There are Child Death Paediatric Liaison Nurses within local hospitals. Part of their role is to ensure that each child death is reported to the CDOP. In addition to this they inform the community and other hospitals to allow them to modify their records accordingly and in a timely manner. If the death occurs in the community there is a process in place whereby the "safeguarding lead" within a GP practice will inform the Paediatric Liaison Nurse.

7. The Paediatric Liaison Nurse informs the CDOP by filling in a specific form online on the "Sentinel system" (see below for more details). This notifies the CDOP team who then notify a number of relevant agencies via email and ask them to complete an agency return on Sentinel. This form is 17 pages long and contains detailed information about all factors relating to the death, including family factors. The majority of the form involves selecting pre-determined options and there is space available for free-text completion.

8. The agencies required to complete the form vary depending on the type of death. For neonatal deaths it will include social care, General Practice, secondary care and the police. For non-neonatal deaths, youth offending services and mental health are also included. The agencies will be given the details of family members where possible, allowing them to check whether they have had any contact with the family, as well as the child.

9. The CDOP team then merge all agency returns into a single report for the CDOP panel to view. Panel members are emailed a notification and case number and log on to a secure server where they can read the report in advance of the meeting.

Panel members

10. In the MCDOP, the meetings are chaired by a Consultant in Public Health. There tends to be 12-16 panel members. They have a fixed core membership to review cases, with flexibility to co-opt other relevant professionals as and when appropriate. The members are:

• Consultants in Public Health
• Consultant Paediatricians (Neonatologists for the neonatal CDOPs)
• Legal Services
• Children's Services
  • Social Care
  • Education
• Designated Nurse
• Merseyside Police
• CDOP/Specialist Nurse
• Bereavement Services
• Lay Members (x2)

The CDOP meeting

11. CDOP panel meetings last around three hours. The case is summarised and presented to the group. An analysis proforma is used to guide panel members with the aim being to decide whether there are modifiable or non-modifiable factors involved in the child's death. If there are modifiable factors then recommendations are put in place to attempt to address these.

Systems: Sentinel

12. This system was developed by the MCDOP with a private provider. It allows the completion and submission of the initial notification form by the Paediatric Liaison Nurse and generates a case number (see below for more details). It is the system where each agency completes and submits the agency return form. It is also where the completed analysis proforma is submitted after the CDOP panel meet. It can provide additional benefits - for example the Paediatric Liaison Nurse can tick an option to let other agencies know of the child's death.

13. Information sharing agreements and safeguards were put in place prior to Sentinel being used for the CDOP process. For data security there is an audit trail showing who has accessed a particular file. Training was provided by the CDOP manager and administrative manager to all agencies involved in completing the Sentinel forms.

14. The system can provide simple quantitative analysis of the data entered. The development of this feature is still in progress. The qualitative aspects of the data collection form are used to inform the report which goes to the CDOP panel. This data do not get collated at a national level as this would be too difficult to analyse. However, they are helpful for informing the report.

15. As the form is online, any revisions can be made immediately and the updated form will be immediately in use for the next user.

16. This is a system developed by MCDOP, however other areas in England are showing interest in using it.

Funding requirements

17. This section is in no way deemed complete and is drawn from discussions with the MCDOP coordinator. Specific costings are not provided.

18. In order for the process to be successful, funding is required for:

• Dedicated CDOP coordinator and administrative support (in this case for an area in which around 85 deaths per year occur there is requirement for one CDOP coordinator, one administrative manager and four part time administrators)
• IT system which allows notification of a child's death, the collection of all relevant data, which is secure, which ensures relevant individuals and agencies are notified of a new case report, and from which data can be readily drawn for analysis
• Protected time for panel members - not only for CDOP meetings but time to read documents in advance of meetings.

19. Additional desirable aspects for which funding would be required:

• Psychological support for panel members

20. It is assumed there would be no other capital costs (e.g. existing building space can be used to house the team). There may be cost savings in combining local areas into a regional panel, however we do not have evidence for this.

21. This does not include recurrent costs such as for paper and other consumables.

Governance

22. The MCDOP produces a quarterly and annual report which is made available to all areas. Each council area has a CDOP sub-group to scrutinise their performance. There is performance management by the LSCB.

23. The Department for Education are notified of all reviews and do a cross-check of death notifications. The Department for Education produce a regular report which combines data from all CDOP returns nationally.

24. The Department for Education also has a CDOP contacts list which allows CDOPs to contact other CDOPs. There is no formal mechanism for sharing lessons but if a modifiable factor is identified which could have national implications it can be shared with other CDOPs through this route.

25. There is no formal national level review or inspection of CDOPs (although they may be part of Ofsted reviews of LSCBs).

Links to other reviews

26. The MCDOP manager did not feel that there was any way of adding the CDOP process on to existing child death review processes for example health reviews, as these reviews vary significantly from area to area. Having a separate child death review process is felt to be more effective.

27. There is no requirement for other agencies to share results of their internal reviews - for example hospital department critical incident reviews - although most do. The panel do not have powers to demand to see these reviews and it was felt that having these powers may be helpful.

28. If there is a serious case review or criminal investigation the CDOP will be suspended until these are complete.

Other points

• The panel members, including the chair, are not necessarily independent. The MCDOP manager gave an example where having by chance a Paediatrician from another area on a review panel meant that they highlighted a concern with the care provided and perhaps this may not have occurred if the Paediatrician had come from that particular area.
• A benefit of a merged CDOP is that it allows there to be a rota for panel members - for example there are three paediatricians who only need to attend two non-neonatal CDOPs per year. This assists with continuity and also may help reduce staff burnout.
• The MCDOP have arranged for psychological support to be available to panel members if required. This is thought to be very important.
• Panel members feeling able to challenge any aspect of the review process is seen as being crucial to ensuring modifiable factors are not missed.
• One of the local Coroners is a very positive force and will use his powers to gain additional information if the panel itself has not managed. For example he has ensured GPs complete the agency return form, even when they have asked to be paid for it. Therefore it may be possible to use existing powers to strengthen the child death review panel's ability to gain information.
• There is no formal mechanism to re-visit the recommendations made to check that a particular agency or body has made changes with regards to modifiable factors identified in a child's death.