11.2 Reviewing All Childhood Deaths

1. Introduction

Working Together to Safeguard Children (2006) (archived) introduced new responsibilities for Safeguarding Children Boards in relation to the review of all deaths in children under 18. This has since now been amended by Working Together to Safeguard Children 2013 and 2015, (Chapter 5), which contains provide clarification on the responsibilities of LSCBs and greater detail regarding the role and functions of the CDOP in terms of notification, monitoring response, information sharing, meetings, case discussions and classification and data collection.

This document should be read in conjunction with the Investigation of all Unexpected Deaths in Childhood Procedure – to follow.

The purpose of the review process is to gain an understanding of the circumstances of the child’s life and death, including the possibility of abuse or neglect (and thus providing a safety net to identify possible Serious Case Reviews). One output will be the learning of common lessons which will be useful in the formulation of public health strategies.

The exercise will largely be paper based but will involve the convening of regular standing panel discussions of individual cases.

Functions of Overview Panels include:

  • Implementing, in consultation with the Local Coroner, local procedures and protocols that are in line with this guidance on enquiring into unexpected deaths and evaluating these together with information about all deaths in childhood;
  • Collecting and collating an agreed minimum data set and, where relevant, seeking information from professionals and family members;
  • Meeting frequently to evaluate the routinely collected data on the deaths of all children, and thereby identifying lessons to be learnt or issues of concern with a particular focus on inter-agency working to safeguard and promote the welfare of children;
  • Having a mechanism to evaluate specific cases in depth, where necessary, at subsequent meetings;
  • Monitoring the appropriateness of the responses of professionals to an unexpected death of a child, reviewing the reports produced by the rapid response team on each unexpected death of a child, making a full record of this discussion and providing the professionals with feedback on their work. 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;
  • Referring to the Chair of the NSCB any deaths where, on evaluating the available information, 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;
  • Informing the Chair of the NSCB where specific new information should be passed to the Coroner or other appropriate authorities;
  • Providing 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;
  • Monitoring the support and assessment services offered to families of children who have died;
  • Monitoring and advising the NSCB on the resources and training required locally to ensure an effective inter-agency response to child deaths;
  • Organising and monitoring the collection of data for the nationally agreed minimum data set, and making recommendations for any additional data to be collected locally;
  • Identifying any public health issues and considering, with the Director of Public Health, how best to address these and their implications for both the provision of services and for training; and
  • Co-operating with regional and national initiatives – e.g. the Confidential Enquiry into Maternal and Child Health (CEMACH)- to identify issues on the prevention of unexpected child deaths.

2. Procedure

2.1 General

The NSCB will discharge its responsibilities via the Standing Child Death Review Panel convened and chaired by the SCB chair or his/her representative who must be a member of the SCB. If the child is normally resident outside the area covered by the SCB, the Chair or (the NSCB Business Manager) will ensure that their opposite number in the relevant NSCB area is informed and sent the information.

The death will normally be reviewed by the Panel of the area where the child is usually resident.

2.2 Notification

Deaths, birth to 18th birthday, should be notified by the person certifying the death to the NSCB Child Death Overview Panel administrator or via other agreed local arrangement.

The NSCB will designate a coordinator of the Board to receive notifications on its behalf.

The Chair of the Child Death Overview Panel is responsible for ensuring the notification process works well.

2.3 Data Collection

The Coroner will be requested to send post-mortem and other relevant reports to the Child Death Overview Panel administrator.

Reports must always be obtained where a Post Mortem examination has taken place.

2.4 Parental Involvement

Consideration will be given as to the degree of involvement of families by the SCB. Parents will be informed of the work of the Panel and will be invited to contribute and/or receive feedback.

2.5 Panel Meetings

The Child Death Overview Panel will meet monthly.

Panel membership will reflect the organisations represented on the SCB, with co-optees. The core membership and co-optees will be determined by local procedures and by the individual circumstances of the child’s death.

Panel members will also consider relevant topics from Public Health and have bereavement as services as a standing agenda item.

2.6 Annual Report

The work of the Panel will be presented in the form of an annual report to the NSCB.

2.7 Review of Arrangements

Child Death Overview Panel arrangements will be reviewed regularly.

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