View Working Together View Working Together

9.2.2 Child Death Overview Panel


  1. Introduction
  2. Statutory Responsibilities
  3. Core Functions of the Child Death Overview Panel
  4. Membership, Accountability and Reporting Arrangements
  5. Confidentiality
  6. Child Protection Concerns
  7. Panel Process
  8. Preventing Childhood Deaths
  9. How to Respond to Deaths of Children with Life Limiting or Life Threatening Conditions
  10. Involvement of Parents and Family Members
  11. Duties of Registrars
  12. Duties and Powers of Coroners
  13. Working with the Media

    Appendix 1: Directory of Bereavement Support and Counselling Services

1. Introduction

1.1 As set out in Working Together 2010 (now archived) there are two interrelated processes for reviewing deaths in childhood:
1.2 In addition to the Child Death Overview Panel, Solihull, Warwickshire and Coventry Local Safeguarding Children Boards convene a joint Child Death Overview Panel, which meets at a minimum of two occasions per year, and is known as The Sub-Regional Child Death Overview Panel. The Sub-Regional Child Death Overview Panel will carry out a thematic/trend analysis with a focus on identifying learning and ultimately improving prevention and safeguarding.

2. Statutory Responsibilities

2.1 When a child/ren dies within the area in which s/he normally resides, the LSCP must collect and analyse information about each death with a view to identifying:
  • Any case giving rise to the need for a Serious Case Review;
  • Any matters of concern affecting the safety and welfare of children in the area of the authority; and
  • Any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area.

The LSCP, through the Child Death Overview Panel, also has a responsibility to put in place procedures for ensuring that there is a co-ordinated response by the Local Authority, their Board Partners and other relevant persons to an unexpected death of a child. An unexpected death is defined as 'the death of an infant or child (less than 18 years old) which:

  • Was not anticipated as a significant possibility for example, 24 hours before the death; or
  • Where there was a similarly unexpected collapse or incident leading to or precipitating the events which led to the death
2.3 When a child dies outside of the area in which s/he normally resides (unless the death occurred in hospital), the review would normally be undertaken by the area where the death occurred, who would liaise with the area of permanent residence. The two LSCPs will conduct, joint reviews, with the LSCP where the child was normally resident leading the review. In the event of this, the Child Death Review Managers will discuss and propose the management arrangements in each case and this must be agreed by the Chairs of the Child Death Overview Panels to ensure there is a uniform response.
2.4 When a child dies out of his/her area, the information should be shared between Child Death Review Managers within one working day.
2.5 As noted above, children who die in hospital, should normally be reviewed by the Child Death Overview Panel for the area where they live.
2.6 In the event of the death of child looked after the LSCP for the Local Authority the child was Looked After by will lead the review.
2.7 When children die abroad, they should be reviewed by the Child Death Overview Panel for the area where they lived.

3. Core Functions of the Child Death Overview Panel

3.1 The Panel will review all deaths of children up to 18 years old within Solihull (excluding still born babies or planned terminations by law) using the National Core Dataset as set out in the Notification and Recording of Child Death Procedure.

The key functions of the Panel are:

  • To evaluate specific cases in depth, where necessary to learn lessons or identify issues of concern;
  • To identify significant risk factors and trends in individual child deaths and in the overall patterns of deaths in Solihull, including relevant environmental, social, health and cultural aspects of each death, and any systemic or structural factors affecting children's wellbeing to ensure a thorough consideration of how such deaths might be prevented in the future;
  • To identify any public health issues and consider, with the Director of Public Health and other provider services, how best to address these and their implications for both the provision of services and for training;
  • To identify and advocate for needed changes in legislation, policy and practices to promote child health and safety and to prevent child deaths;
  • To increase public awareness and advocacy for the issues that affect the health and safety of children;
  • Where concerns of a criminal or child protection nature are identified, to ensure that the police and coroner are aware and to inform them of any specific new information that may influence their inquiries; to notify the Chair of Solihull LSCP of those concerns and advise the chair on the need for further enquiries under section 47 of the Children Act 1989 (see Section 47 Enquiry), or of the need for a Serious Case Review;
  • Notify the Chair of the LSCP where specific new information should be passed to the coroner or other appropriate authorities;
  • To improve agency responses to child deaths through monitoring the appropriateness of the response of professionals to each death of a child, including reviewing reports of unexpected deaths produced by the rapid response team and providing the professionals concerned with feedback on their work;
  • To 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;
  • To monitor the support and assessment services offered to families of children who have died;
  • To monitor and advise Solihull LSCP on the resources and training required locally to ensure an effective inter-agency response to child deaths;
  • To co-operate with any regional and national initiatives in order to identify lessons on the prevention of child deaths.

4. Membership, Accountability and Reporting Arrangements

4.1 The Child Death Overview Panel will have a permanent core membership drawn from the following key organisations / professions represented on Solihull LSCP:
  • Designated Doctor for Unexpected Deaths;
  • Public Health;
  • Children's Social Work Services;
  • Police Child Abuse Investigation Unit;
  • Midwifery;
  • Legal Services.

Consideration will be given to including any or all of the following to contribute to the discussion of certain types of death when they occur:

  • Emergency Department medical and nursing staff;
  • Other paediatric input;
  • Palliative Care Service;
  • Obstetric staff;
  • Coroner's Office;
  • Other police representatives including accident investigators;
  • Fire Services;
  • Registrar of Births, Deaths and Marriages;
  • Education;
  • Ambulance/ paramedic services;
  • Paediatric pathologist;
  • Child & Adolescent Mental Health Services;
  • Adult Mental Health;
  • Voluntary Agencies;
  • Traffic and Road Safety;
  • Department for Communities and Local Government;
  • Royal National Lifeboat Institute;
  • Community Safety;
  • The Youth Offending service (where a child or young person has died whilst under supervision or within 3 months of the expiry of the supervision);
  • Others as required.
4.2 The Child Death Overview Panel will be accountable to the chair of Solihull LSCP.
4.3 The Child Death Overview Panel is responsible for developing its work plan, which should be approved by the LSCP. It will prepare an annual report for the LSCP, which is responsible for publishing relevant, anonymised information.

Solihull LSCP 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.

The LSCP will supply data regularly on every child death as required by the Department Of Education (DoE) to bodies commissioned by the Department to undertake and publish nationally comparable, anonymised analyses of these deaths.

5. Confidentiality

5.1 Information on individual children presented to the Child Death Overview Panel meetings will be anonymised and will not be retained by individual members of the Panel after the meeting.
5.2 Members of the Child Death Overview Panel will sign and uphold a confidentiality statement. This statement will be reaffirmed at each meeting through signing the Attendance Log within the confidentiality statement.

6. Child Protection Concerns

6.1 Where there is an ongoing criminal investigation, the Crown Prosecution Service must 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.
6.2 If during the enquiries, concerns are expressed in relation to any surviving children, immediate discussions must take place with Children's Social Work Services.

7. Panel Process

7.1 The Panel will receive a completed Form B in respect of all deaths and, as far as possible, a partially completed Form C - see Notification and Recording of Child Deaths Procedure.
7.2 Deaths will be analysed using four domains set out in the Factors Contributing to Childhood Deaths Framework.

The influence of the factors in the above domains will be determined as follows:

0 - Information not available
1 - No factors identified or factors identified that are unlikely to have contributed in any way to the death
2 - Factors identified that may have contributed to vulnerability, ill health or death
3 - Factors identified that provide a complete and sufficient explanation for the death
7.4 Having considered the different factors that may have a bearing on the child's death, the Panel will evaluate the extent to which the death was preventable using the following definitions:

Preventable - Modifiable factors

A preventable child death is one in which modifiable factors may have contributed to the death. Modifiable factors are those which, according to nationally or locally achieved interventions, could be modified to reduce the risk of future child deaths.

Not preventable - No Modifiable factors

Death caused by intrinsic or extrinsic factors, with no identified modifiable factors
7.5 The Panel will also consider:
  • Whether any deaths should be referred to the police/coroner for further investigation;
  • Whether any deaths should be referred to the Local Safeguarding Board for a Serious Case Review;
  • What the best strategies for prevention might be;
  • Whether there is a need for any system changes in relation to the way childhood deaths are responded to.

8. Preventing Childhood Deaths

8.1 The most important reason for reviewing child deaths is to improve the health and safety of children and to prevent other children from dying. The Child Death Review Panel will therefore maintain a focus on prevention through all its work.
8.2 Individual deaths and overall patterns of childhood deaths will be evaluated to determine if the deaths were preventable; to identify modifiable risk factors and to determine the best strategies for prevention.
8.3 Strategies may be considered at different levels:
  • Strengthening individual knowledge and skills - assisting individuals to increase their knowledge and capacity to act leading to behaviour change, through education, counselling and individual support;
  • Promoting community education - training service providers to improve knowledge, skills, capacity and motivation to effectively promote prevention;
  • Fostering coalitions and networks of individuals and organisations to work for advocacy and health promotion;
  • Changing organisational practices where system failures are identified, or models of good practice highlighted;
  • Mobilising neighbourhoods and communities in the process of identifying, prioritising, planning and making changes;
  • Influencing policy and legislation where appropriate through local and national advocacy.
8.4 Recommendations made by the Child Death Review Panel will be based on the lessons learnt from the review of child deaths, will be focused on specific, measurable actions, and will include plans for monitoring implementation.

9. How to Respond to Deaths of Children with Life Limiting or Life Threatening Conditions


Chronic illness, disability and life limiting/life threatening conditions account for a large proportion of child deaths. Professionals responding to the death of a child with a LL/LT condition should ensure that:

  • Their response to these families is appropriate and supportive;
  • Does not cause any unnecessary distress at a time when they are dealing with the tragic but anticipated, natural death of their child;
  • And that their child's expected death can be dignified and peaceful.
9.2 End of life care plans may be in place and therefore families, where appropriate, should be supported, to choose where their child's body is cared for after death for example a children's hospice.
9.3 The lives of children with LL/LT conditions are as valued and important as those of any other children,so In circumstances where a child with a life limiting/life threatening condition dies in manner or at a time that was not anticipated, the rapid response team should liaise closely and promptly with a member of the medical, palliative or end of life care team, who knows the child, to jointly determine how best to respond to that child's death mindful that the response should be appropriate and supportive and does not cause any unnecessary distress to families at a time when they are dealing with the tragic death of their child.

10. Involvement of Parents and Family Members

10.1 Parents and family members should be informed that their child's death will be reviewed, and often have significant information and questions to contribute to the review process. In each individual circumstance a professional will be identified to support the family through the process.

The LSCP will ensure that

  • Parents and family members are given information about the working of the Child Death Overview Panel and are assured that the objective of the child death review process is to learn lessons in order to improve the health, safety and well being of children and ultimately, hopefully, to prevent further such child deaths. The process is not about culpability or blame.
  • The Child Death Overview Panel should agree what information is to be shared with parents and family members and ensure that the identified professional known to the family conveys to them information in a sensitive and timely manner;
  • Decisions on information sharing (i.e. what information is shared, with whom, and why) must be recorded in each agency's records;
  • Parents are encouraged to and able to contribute any comments or questions they might have to the review of their child's death.

Parents or other family members are not be able to attend the Panel meeting as this is a meeting for professionals to discuss not only the individual case but also wider public health issues. Questions and comments forwarded by parents and family members will be considered and responded to.

10.4 Parents should be informed that all cases will be anonymised prior to discussion by the Panel, information gathered will be stored securely and only anonymised data will be collated at a regional or national level. Parents should also be made aware that the Panel will make recommendations and report on the lessons learned to the LSCP. The LSCP produces an annual report which is a public document, but it will not contain any personal information that could identify an individual child or their family.
10.5 The Panel should ensure that whenever necessary, arrangements are made for the family to have the opportunity to meet with relevant professionals, for example a professional known to the family before their child died, a paediatrician or a police officer to help answer their questions.

11. Duties of Registrars


Registrars of Births and Deaths are required by the Children and Young Persons Act 2008 to supply LSCPs with information which they have about the deaths:

  • Of persons aged under 18 in respect of whom they have registered the death; or
  • Of persons in respect of whom the entry of death is corrected and it is believed that person was or may have been under the age of 18 at the time of death.

Registrars must also notify LSCPs if they issue a Certificate of No Liability to Register where it appears that the deceased was or may have been under the age of 18 at the time of death.

11.2 Registrars are required to send the information to the appropriate LSCP no later than seven days from the date of registration, the date of making the correction/ update or the date of issuing the certificate of no liability as appropriate. These requirements apply in respect of deaths occurring on or after 1 April 2009.

12. Duties and Powers of Coroners


The Coroners (Investigations) Regulations 2013 place a duty on coroners to inform the LSCP, for the area in which the child died or the child’s body was found, where the coroner decides to conduct an investigation or directs that a post mortem should take place. The coroner must provide to the LSCP all information held by the coroner relating to the child’s death. 

Where the coroner makes a report to prevent other deaths, a copy must be sent to the LSCP.
12.2 On receipt of an initial report of a death of a child, the LSCP with an interest in this information should inform the coroner of the address(es) (including email address(es)) to which future information should be supplied. If any information comes to the attention of an LSCP which it believes should be drawn to the attention of the relevant coroner, then the LSCP should consider supplying it to the coroner as a matter of urgency.

13. Working with the Media

13.1 Media interest in the work of the Child Death Overview Panel will be dealt with through the Local Authority Press Office, which supports the work of the LSCP. The annual report of the Child Death Overview Panel will be a public document, which will have no identifiable information.

Appendix 1: Directory of Bereavement Support and Counselling Services

Click here to view Directory of Support and Counselling Services.