Derby and Derbyshire Safeguarding Children Partnership
All agencies work together to keep children and young people safe
The Child Death Review Process
The death of a child is a devastating loss that profoundly affects bereaved parents as well as family members, friends and professionals who were involved in caring for the child in any capacity. Families should be met with empathy and compassion. They need clear and sensitive communication. They also need to understand what happened to their child and know that people will learn from what happened. The process of expertly reviewing all children's deaths is grounded in deep respect for the rights of children and their families, with the intention of preventing future deaths. The Child Death Review process takes the following steps:
- If the child’s death was sudden or unexpected, a Joint Agency Response begins. This could mean that families are visited by police officers, social workers and/or health professionals.
- Information about how the child died, including their history, is collected.
- A Child Death Review meeting is held to review all the information to understand why the child died. This meeting will identify learning points from services involved with the child leading up to their death. The outcomes of this meeting are shared with the Child Death Overview Panel (CDOP)
- The independent Child Death Overview Panel (CDOP) meeting takes place to look at the deaths of all under 18s in Derby & Derbyshire. Panel members will not have been directly involved in the child's life or death and personal details will remain anonymous.
- The information from the CDOP is shared with the National Child Mortality Database to assist in building a national picture of child deaths across the country.
The "When a child dies: a guide for parents and carers" has been put together by a group of bereaved parents, support organisations and professionals. It is for parents/carers of a child under 18 to help them understand some of the things that will happen and inform of support that is available.
The statutory child death notification form is arguably the most important form in the child death review process. Not only does it notify CDOP of the child death, but when completed well, provides a comprehensive list of all the professionals who cared for the child during their life (or mother in pregnancy) and immediately after their death. This enables the coordinator to carry out the rest of the process and gather information for review.
Please provide details of key professionals on the notification form.
To submit a notification for a Derbyshire child death click on: https://www.ecdop.co.uk/Derbyshire/Live/Public.
You do not need an eCDOP log in to submit a child death notification and professional can submit one.
For guidance: Notification guidance for CDR professionals | National Child Mortality Database (ncmd.info)
The JAR is a coordinated multi-agency response (on-call health professional, police and social care) which is triggered if a child's death:
- Is sudden (not predicted 24 hours before) and there is no immediately apparent cause (including SUDI/C).
- In the case of a stillbirth where no healthcare professional was in attendance.
The decision to initiate a JAR is not always clear. Following discussion, the ultimate decision remains with the Coroner.
The aims of the JAR are:
- To establish, as far as possible, the cause/s of the child's death.
- Identify any potential contributory or modifiable factors
- Provide ongoing support for the family.
- Ensure that all statutory obligations are met.
- Learn lessons in order to reduce the risks of future deaths.
Please see the JAR/SUDC guidance on the DDSCP procedures page.
A Child Death Review Meeting (CDRM) is a meeting of the professionals directly involved in the child’s care during their life or who may have taken part in the investigation following their death.
It takes place once initial investigations have been completed and is usually held within three months of the child's death. The place where the child died should lead on the child death review meeting. This is usually the hospital where the child died or in a community setting (such as a GP surgery). The meeting may be delayed if there are ongoing investigations or if the post-mortem report takes a long time to complete.
The aims of the CDRM are:
- To review background history, treatment and outcomes of investigations to determine the likely cause of death.
- To ascertain contributory and modifiable factors
- To identify any learning and actions to improve the safety/welfare of children or the child death review process.
To ensure that support is provided to the family and they are provided with the outcomes from investigations (including the postmortem) and any learning from the review meeting. If bereaved families have any questions or would like to raise any issues, these can be shared with the allocated key worker or with the Lead Nursed for Child Death reviews, so that their voices can be heard at the Child Death Review Meeting.
The Child Death Overview Panel is an multi-agency panel who have a statutory responsibility under Working Together to Safeguard Children (2023) and Child Death Review: Statutory and Operational Guidance (2018) to review all deaths of children from birth to the 18th birthday who are residents of Derby and Derbyshire. CDOP provide independent multi-agency scrutiny on behalf of the local child death review partners.
The aims of the panel are to:
- Learn from the deaths of children to help identify ways of preventing future deaths
- Identify any improvements that can be made in the services provided to children and their families
- Improve the experience of bereaved families and support professionals to care for families effectively
The panel meets after all the information about the death has been gathered through the child death review process. The panel is a confidential forum, the cases are anonymised however each child is discussed individually and the panel seek to learn from each child death.
Any learning is shared with practitioners and their organisations both locally and nationally.
Derby and Derbyshire CDOP welcome the views of parents and carers and ensure the voices of the child and family are heard during the panel.
The initial days, weeks and months following a child's death are extremely difficult. Grief is a personal experience and has no set time or process. There is no right or wrong way to grieve. As such engaging with support is an individual/personal choice and different methods/approaches will suit. It is, however, essential that all have access, and are signposted, to support. Whether that be a family member, friend or professional.
www.ataloss.org is a useful website to find local/regional/national support services
The Derbyshire Bereavement Hub is also a useful website for local services available.
If parents/carers or professionals would like to discuss support available, or to ask any questions about the child death review process or CDOP please contact Kayleigh McMahon - Lead Nurse for Child Death Review (details below).
A priority for the DDSCP and CDOP is the safety of babies. The Keeping Babies Safe Strategy (v2) (Nov 24) is a researched based strategy to promote the safety of babies through a multi-agency approach and to deliver consistent clear messages on:
- Safer Sleep
- Safe Handling
- Safe Space
Derby and Derbyshire CDOP Annual Report
The findings from child deaths are used to inform local strategic planning on how to best safeguard and reduce harm in children and to promote better outcomes for our children in the future.
National Child Mortality Database (NCMD) Reports
The National Child Mortality Database (NCMD) gathers information on all children who die across England. The aim is to learn lessons that could lead to changes to improve and save children’s lives in the future. Further information and reports can be found on their website www.ncmd.info
CDOP Newsletters
The Lead Nurse for Child Death Review produces regular newsletters promoting learning from CDOP.
Chair of CDOP/Designated Nurse Safeguarding Children
Juanita Murray - juanitamurray@nhs.net
The role of CDOP Chair is to:
- Chair the CDOP Meeting
- Report the progress of the Child Death Review Arrangements to the Child Death Review Partners
- Ensure that CDOP functions well and fulfils the statutory requirements around the reviewing of child deaths.
- Ensure that any learning from CDOP is disseminated widely within the partnership
- Escalate any concerns or risks that are identified by CDOP to the Child Death Review Partners
- Write the Annual Report with the Designated Doctor for Child Death
- Provide leadership and support to the Lead Nurse for Child Death Review and the CDOP meeting.
Designated Doctor for Child Death
Dr Nic Medd - Nic.medd@nhs.net
The Designated Doctor is:
- Responsible for the child death review process.
- Advises CDOP regarding necessary experts required to inform ordinary and themed panels.
- Advises CDOP on the identification of modifiable and contributory factors.
- Assists CDOP in the development and implementation of appropriate preventative strategies to reduce child deaths.
- Provides advice as required including to deaths on adult ITU.
- Prepares and present cases at CDOP.
- Produces the annual report along with the Chair of CDOP.
Lead Nurse for Child Death Reviews in Derby & Derbyshire
Kayleigh McMahon - Kayleigh.mcmahon2@nhs.net (Tel: 07584 880720)
The Lead Nurse works in collaboration with the Chair of CDOP/Designated Nurse for Safeguarding Children & the Designated Doctor for Child Death in the implementation, co-ordination and day-to-day management of the child death review process.
Taking the lead by:
- Having oversight of all child deaths in Derby and Derbyshire to ensure a robust and high-quality child death review process.
- Working closely with providers/agencies; to provide advice, support and guidance through the child death review process.
- Being the named link person for Families (until case heard at CDOP):
- To ensure they have an identified key worker from a health provider.
- To signpost families to bereavement support and ensure they get appropriate support from services when needed.
- To ensure families understand the Child Death Review Process and have their voices heard and questions answered.
- Ensuring consistency of child death review meetings and that they occur in a timely manner.
CDOP Co-Ordinator
Elizabeth Ellis - dhcft.cdopderbyshire@nhs.net (Tel: 01332 623700 ext 31526)
The CDOP Coordinator has oversight of the child death review process (from notification to CDOP review). Ensuring compliance with statutory requirements by gathering information, coordinating meetings, securely managing confidential data and reports within the eCDOP system, and facilitating effective communication among professionals involved in the review process. The Coordinator provides administrative and coordination support and maintains professional relationships.
Derby and Derbyshire Safeguarding Children Partnership includes:
