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An Overview of the Child Death Review Process


Contents

1. Overall Principles
2. What is an Unexpected Death?
3. Chronic Illness, Disability and Life Limiting Conditions
4. Where Professionals are Uncertain about Whether a Death is Unexpected
5. Definition of Preventable Child Deaths
6. Hull Safeguarding Children Board Responsibilities for the Child Death Review Processes
  6.1 The aim of the Rapid Response
  6.2 An Overview of all Child Deaths up to the Age of 18 Years
7. The Aim of Child Death Reviews
8. Enquiries Should:
9. Involvement of Parents/Carers and Family Members (for all child deaths)
10. Child Death Reviews and Serious Case Review Interface
11. Use of Child Death Information to Prevent Future Deaths
  Further Information


1. Overall Principles

Each death of a child is a tragedy for his or her family (including any siblings), and subsequent enquiries/investigations should keep an appropriate balance between forensic and medical requirements and the family's need for support.

A small minority of unexpected deaths are the consequence of abuse or neglect or are found to have abuse or neglect as an associated factor. 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;
  • Address the needs of all family members; and
  • 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 should approach their enquiries with an open mind.


2. What is an Unexpected Death?

This guidance relates to the deaths of all children from birth (excluding those deaths set out in Serious Case Reviews Procedure) up to the age of 18 years.

An unexpected death is one where:

  • The death of an infant or child which was not anticipated as a significant possibility for example, 24 hours before the death;

    or
  • Where there was an unexpected collapse or incident leading to or precipitating the events which lead to the death.

NB: (Reviews of deaths which follow a planned termination under the law (Abortion Act 1967) should not be carried out by Child Death Overview Panels even in instances where a death certificate has been issued. If Hull Safeguarding Children Board has general concerns about local procedures relating to planned terminations, it should contact the Care Quality Commission (enquiries@cqc.org.uk). All other deaths (i.e. excluding those deaths which follow a planned termination of pregnancy under the law) which have been registered as live with the General Registrar's Office, should be reviewed by the Child Death Overview Panel).


3. Chronic Illness, Disability and Life Limiting Conditions

Chronic illness, disability and life limiting conditions account for a large proportion of child deaths. Whilst it is to be expected that children with life limiting or life threatening conditions (LL/LT conditions) will die prematurely young, it is not always easy to predict when, or in what manner they will die.

The lives of children with LL/LT conditions are as valued and important as those of any other children, and hence, the unexpected death of a child with LL/LT conditions should be managed as for any other unexpected death so as to determine the cause of death and any contributory factors.


4. Where Professionals are Uncertain about Whether a Death is Unexpected

Where professionals are uncertain about whether a death is unexpected, the Designated Paediatrician responsible for unexpected deaths in childhood should be consulted. If there is any doubt, the procedures outlined in this protocol should be followed until the available evidence enables a different decision to be made.


5. Definition of Preventable Child Deaths

Preventable child deaths are defined as those in which modifiable factors may have contributed to the death.

Modifiable factors are defined as those, where, if actions could be taken through national or local interventions, the risk of future child deaths could be reduced; for example, in the family environment, parenting capacity or service provision.


6. Hull Safeguarding Children Board Responsibilities for the Child Death Review Processes

This section gives an overview of the Hull Safeguarding Children Board responsibility for responding to and learning from all childhood deaths.

The Child Death Review Process is one of the core functions of Hull Safeguarding Children Board set out in Regulation 6 of the Local Safeguarding Children Boards Regulations (2006)

When a child dies in Hull Safeguarding Children Board area, covered by a Child Death Overview Panel (CDOP), there are two interrelated processes for reviewing child deaths either of which can trigger a Serious Case Review (SCR).

6.1 The aim of the Rapid Response

  1. Rapid response - This involves a group of key professionals who come together and are co-ordinated by the Designated Paediatrician for the purpose of enquiring into and evaluating each unexpected death of a child.

The aim of the rapid response is:

  • Responding quickly to the unexpected death of a child;
  • Making immediate enquiries into and evaluating the reasons for and circumstances of the death, in agreement with the Coroner;
  • Undertaking the types of enquiries/investigations that relate to the current responsibilities of their respective organisations when a child dies unexpectedly. This includes liaising with those who have ongoing responsibilities for other family members;
  • Collecting information in a standard, nationally agreed manner;
  • Providing support to the bereaved family, and where appropriate referring on to specialist bereavement services; and
  • Following the death through, and maintaining contact at regular intervals with family members and other professionals who have ongoing responsibilities for other family members, to ensure they are informed and kept up-to-date with information about the child's death.

NB: If, during enquiries, concerns are expressed in relation to the needs of surviving children in the family, discussions should take place with Children's Social Care. It may be decided that it is appropriate to initiate Children's Social Care Assessment (see Contacts and Referrals with Children’s Social Care Procedure).

6.2 An Overview of all Child Deaths up to the Age of 18 Years

An overview of all child deaths up to the age of 18 years (excluding both those babies who are stillborn and planned terminations of pregnancy carried out within the law) in the Hull Safeguarding Children Board area, is undertaken by a panel).

  • A sub-committee of Hull Safeguarding Children Board known as the Child Death Overview Panel (CDOP) are responsible for reviewing the available information on all child deaths, and are accountable to the Hull Safeguarding Children Board Chair. The disclosure of information about a deceased child is to enable Hull Safeguarding Children Board to carry out its statutory functions relating to child deaths;
  • Hull Safeguarding Children Board uses the aggregated findings from all child deaths, collected according to the nationally agreed minimum data set to inform local strategic planning on how best to safeguard and promote the welfare of children in the Hull area.


7. The Aim of Child Death Reviews

The aim of the Child Death Review is to collect information about the deaths of all children in the Hull area, so that the overview panel can:

  • Identify whether there are any patterns or trends emerging locally;
  • Identify any lessons that can be learned about the patterns of deaths locally;
  • Based on that knowledge - take action to improve the safety and well being of children in the area; and
  • Ensure that where possible further deaths of children can be avoided.


8. Enquiries Should:

  • Seek to understand the reason for the child's death;
  • Address the needs of other children in the household;
  • Address the needs of all family members;
  • Be conducted in a way that ensures families are treated with sensitivity, discretion and respect at all times;
  • Be approached with an open mind; and
  • Consider any lessons to be learned about how best to safeguard and promote children's welfare in the future.


9. Involvement of Parents/Carers and Family Members (for all child deaths)

Hull Safeguarding Children Board has established mechanisms for informing and involving parents/carers and other family members in both the child death overview and rapid response processes.

The family must be at the centre of the process, fully informed at all times and treated with care and respect. Parents/carers and family members should be informed that their child's death will be reviewed and asked to contribute, as they will often have significant information and questions to contribute to the review process.

Parents/carers and family members should be 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 all children and ultimately, hopefully to prevent further such child deaths. The process is not about culpability or blame.

It is not appropriate for parents/carers to attend the Child Death Overview Panel meeting as this is a meeting for professionals to discuss not only the individual case but also wider public health issues. Parents/carers should however be encouraged to contribute any comments or questions they might have to the review of their child's death.

Parents/carers should be informed that all cases will be anonymised prior to discussion by the CDOP, information gathered will be stored securely and only anonymised data will be collated at a regional or national level. Parents/carers should also be made aware that the CDOP will make recommendations and report on the lessons learned to Hull Safeguarding Children Board.

Hull Safeguarding Children Board 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.

There is a nationally produced leaflet which can be given to parents, carers and family members to explain the Child Death Review process which is available to download from The Lullaby Trust. Click here to view the Leaflet.


10. Child Death Reviews and Serious Case Review Interface

Click here to view Flowchart: Interface between the Child Death and Serious Case Review Processes.

If it is thought, at any time, that the criteria for a Serious Case Review (SCR) might apply, the Chair of Hull Safeguarding Children Board should be contacted and the procedures set out in Serious Case Review Procedure should be followed. If a SCR is initiated, the CDOP will not be able to conclude the child death reviewing process until after the SCR has been published. Similarly, the Child Death Reviewing process will not be able to be completed if the CDOP is awaiting the outcomes of criminal proceedings and/or an inquest. This should not, however, prevent lessons from being learned and from being acted upon in a timely manner.


11. Use of Child Death Information to Prevent Future Deaths

The Child Death Overview Panel prepares an annual report of relevant information for Hull Safeguarding Children Board. This information in turn informs the Hull Safeguarding Children Board Annual Report. It should include the total numbers of deaths reviewed, recommendations made by the panel about required future actions to prevent child deaths, and any further description of the deaths that the panel deems appropriate. It should also include a review of actions taken to implement the recommendations from the previous year's report, and set out any such recommendations which have not yet been fully implemented which are to be carried forward.

N.B. Hull Safeguarding Children Board provides appropriate training to ensure successful implementation of the Child Death Review processes (see Hull Safeguarding Children website).


Further Information

See also Child Death Overview Panel (CDOP) Practice Guidance Including Rapid Response Practice Guidance.

Sudden Unexpected Death in Infancy and Childhood - Multi-agency Guidelines for Care and Investigation (Royal College of Pathologists, endorsed by The Royal College of Paediatrics and Child Health)

End.