The statutory child death notification form is 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 co-ordinator to carry out the rest of the process, without it, gathering information is very challenging. 

Please provide details of key professionals on the notification form

To submit a notification for a Derbyshire child death click on:

You do not need an eCDOP log in to submit a child death notification.

For guidance: Notification guidance for CDR professionals | National Child Mortality Database (

After a child dies, organisations such as schools, social care, GPs are notified.

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 is collected.
  • A Child Death Review meeting is held to review all the information to understand why the child died. They review and identify any learning points from services involved with the child leading up to their death. The outcomes of this meeting are passed on to 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. 

NHS England has published a guide for families setting out the steps that follow the death of a child; When a Child Dies: A Guide for Parents and Carers

A Joint Agency Response (JAR) is when key professionals from: Health Services, Police and Childrens Social Care come together following the unexpected death of a child.

An unexpected death is defined as the death of an infant or child that was not anticipated as a significant possibility 24 hours before the death. It also includes situations where there was a community based unexpected collapse or incident leading to, or precipitating, the child’s eventual death.

A Joint Agency response only happens where the child’s death is:  

  • unexpected. 
  • due to external causes.
  • sudden and there is no apparent cause at the time.
  • in custody, or where the child was detained under the Mental Health Act. 
  • unclear if the cause of death was natural.
  • a stillbirth where there wasn’t a healthcare professional present.

The aim of the JAR is to:

  • Assist HM Coroner in ascertaining a cause of death where possible
  • Identify any potentially contributory factors
  • Ensure support for families
  • Assure families that their child’s death has been fully investigated.
  • Ensure that future children are protected and satisfy any wider public interest concerns

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.

The Child Death Review Meeting takes place once all the information surrounding the death has been gathered and is usually held within three months of the child's death.  It usually takes place in 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.

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. Families can also be offered a follow-up meeting to receive feedback of what was discussed. 

If parents or carers would like to ask any questions about the child death review process or CDOP please contact Kayleigh Noble - Lead Nurse for Child Death Review (details below)

If you think you need some support, this website provides information and links to organisations offering free services for bereaved people (of all ages) in Derby City and Derbyshire.

A priority for Derby and Derbyshire safeguarding children's partnership and CDOP is the safety of babies. The Three Steps for Baby Safety Partnership Strategy is a researched based strategy to promote the safety of babies through a multi-agency approach and to deliver consistent clear messages on:

  • Safe 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. 

CDOP annual report 19-20.pdf

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 can be found on the website

NCMD 2nd Annual Report 20-21.pdf

NCMD Child Mortality and Social Deprivation report May 2021.pdf

NCMD Impact Report Jan-June

NCMD 1st Annual Report 2019.pdf

CDOP Newsletters

The Lead Nurse for Child Death Review produces regular newsletters promoting learning from CDOP.

  1. Jan 2020. CDOP Newsletter.pdf
  2. March 2020. CDOP Newsletter.pdf
  3. May 2020. CDOP Newsletter.pdf
  4. August 2020. CDOP Newsletter.pdf
  5. December 2020. CDOP Newsletter.pdf
  6. February 2021. CDOP Newsletter.pdf
  7. June 2021 CDOP hot topic Drowning.pdf
  8. July 2021 CDOP hot topic Open water Safety.pdf

Chair of CDOP/Designated Nurse Safeguarding Children

Juanita Murray

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

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

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

Alexandra Smith

01332 623700 ext 31526