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8.1 Child Death Overview Panel

Please note: This protocol was approved by the Isle of Man Safeguarding Children Board (SCB) in July 2011. It will be reviewed in July 2013.

RELATED GUIDANCE

See the Isle of Man SCB website - Child Death Overview Panel

RELATED CHAPTER

Serious Case Reviews Procedure

Sudden Unexpected Death In Infants And Children (SUDIC) Procedure


Contents

  1. Introduction
  2. Core Purpose
  3. When a Child Dies who is Not Normally Resident on the Island
  4. When a Child Normally Resident on the Island Dies Elsewhere
  5. Membership
  6. Key Functions of the Child Death Overview Panel
  7. Consent and Confidentiality
  8. Professional and Family Support
  9. Learning from Child Deaths
  10. Reporting Mechanisms

    Appendix 1: Terms of Reference

    Appendix 2: Threshold Criteria for Levels of Discussion of Cases at CDOP

    Appendix 3: Confidentiality Statement

    Appendix 4: Model Letter for Parents

    Appendix 5: Leaflet for Parents

    Appendix 6: Form A – Notification

    Appendix 7: Form B

    Appendix 8: Form C

    Appendix 9: Request for Information Letter


1. Introduction

1.1 This Procedure sets a minimum standard for a Child Death Overview Panel (CDOP).   The Isle of Man Safeguarding Children Board (SCB) has established a CDOP based on the UK model (as outlined in Working Together to Safeguard Children 2010, Chapter 7 (now archived)) whilst taking account of the unique environment of the Isle of Man.
1.2 For more information see Appendix 1: Terms of Reference.
1.3

There are two inter-related processes for reviewing child deaths. Either process can trigger a Serious Case Review. The processes are:

  • A rapid response by a team of key professionals who come together for the purpose of enquiring into and evaluating each unexpected death of a child. This is detailed in the Sudden Unexpected Death In Infants And Children (SUDIC) Procedure for the management of sudden and unexpected childhood deaths;
  • An overview of all child deaths (birth up to 18th birthday, excluding babies stillborn) in the area covered by the Isle of Man undertaken by a panel drawn from relevant agencies.


2. Core Purpose

2.1

When a child dies on the Isle of Man and this is the area within which s/he normally resides, the CDOP will collect and analyse information about each death with a view to identifying:

  • Any matters of concern affecting the safety and welfare of children on the Island;
  • Any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area;
  • Any case giving rise to the need for a Serious Case Review where this has not already been identified.
2.2 The CDOP has responsibility for reviewing the deaths of all children, with priority given to those deaths that are unexpected.
2.3

The CDOP will undertake an overview of all child deaths within the Island’s jurisdiction. This process uses a standard set of forms  to gather information available from those who were involved in the care of the child, both before and immediately after the death, and other sources such as:

  • Case summaries from health records;
  • Case information from police, social care and education;
  • Post mortem reports.
2.4 If the CDOP thinks at any point that abuse or neglect may be a factor in the death of a child this must be referred immediately to the Chair of the SCB for consideration under Serious Case Review arrangements.


3. When a Child Dies who is Not Normally Resident on the Island

3.1

When a child dies on the Island and this is not the area within which s/he normally resides, the CDOP will:

  • Inform the LSCB where the child normally resides;
  • Negotiate any role the ‘home’ LSCB may wish the Isle of Man CDOP to play;
  • Collect and analyse sufficient information about the death to contribute to the overall understanding of deaths on the Island (e.g. road traffic accident spots).


4. When a Child Normally Resident on the Island Dies Elsewhere

4.1 When a child, normally resident on the Isle of Man, dies off Island the CDOP will liaise with the LSCB which covers the area where the child died and negotiate respective roles. The assumption would be that the CDOP of the home area of the child would normally lead and report these deaths, unless there was a specific reason to do otherwise.  If a child dies outside of Island or UK jurisdiction (e.g. on holiday abroad) the CDOP will seek to gain information about the death and consider if there are lessons for local application.
4.2 Children from the Isle of Man who die in an off Island hospital will be reviewed by the Isle of Man CDOP although the CDOP in the area they died must also be informed in order that they can consider the death as part of the overall deaths in their area.
4.3 Children who are under the care of the Social Care but may be placed off Island will be discussed individually by the panel and assessed on individual circumstances with input from social services where necessary.


5. Membership

5.1

The Child Death Overview Panel membership is made up from representatives as follows:

  • Health Services to include:
    • Public Health;
    • Designated Nurse;
    • Designated Paediatrician for Safeguarding;
    • Children’s Hospice.
  • Police;
  • Social Care;
  • CDOP Chair;
  • SCB Chair;
  • SCB Strategic Co-ordinator.
5.2 Other members will be co-opted as and when appropriate. This may be to ensure that the membership of the CDOP best reflects the characteristics of the population, to provide a perspective from the independent sector or to contribute to the discussion of certain types of death e.g. fire service, mental health services, education / early years, bereavement services, palliative care etc.
5.3 The Chair of the CDOP is accountable to the SCB Chair.  


6. Key Functions of the Child Death Overview Panel

6.1 Implementing, in consultation with Coroners, procedures and protocols that are in line with best practice guidance on enquiring into unexpected deaths, and evaluating these together with information about all deaths in childhood.
6.2 Collecting and collating an agreed minimum data set and, where relevant, seeking information from professionals and family members.
6.3 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 effective inter-agency working to safeguard and promote the welfare of children. Appendix 2: Threshold Criteria for Levels of Discussion of Cases at CDOP describes the criteria for levels of discussion of cases at CDOP with examples of each level.
6.4

Having a mechanism to evaluate specific cases in depth, where necessary, at subsequent meetings. This could be to:

  • Review unexplained deaths following 3rd Stage discussion to identify lessons to be learnt;
  • On occasion the CDOP will examine specific cases in more depth following referral from the SCB Chair and/or SCR Panel or the SCB.
6.5 This will be decided on a case-by-case basis.
6.6 Monitoring the appropriateness of the response 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 Attorneys Generals Chambers 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.
6.7 Referring to the Chair of the SCB 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.
6.8 Informing the Chair of the SCB where specific new information should be passed to the Coroner or other appropriate authorities.
6.9 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.
6.10 Monitoring the support and assessment services offered to families of children who have died.
6.11 Monitoring and advising the SCB on the resources and training required locally to ensure an effective inter-agency response to child deaths.
6.12 Organising and monitoring the collection of data for the agreed minimum data set, and making recommendations (to be approved by the SCB) for any additional data to be collected.
6.13 Co-operating with Off Island initiatives – e.g. the Confidential Enquiry into Maternal and Child Health (CEMACH) to identify lessons on the prevention of unexpected child deaths.
6.14 Developing a work plan: this will be approved by the SCB and should conform to the timescales on the SCB work plan. 
6.15 Preparing an annual report for the SCB:  this is responsible for publishing relevant, anonymised information. The CDOP will provide sufficient information for the SCB to disseminate the lessons to be learnt to all relevant organisations in their area, ensuring that relevant findings inform the Children and Young People’s Plan and agencies act on any recommendations to improve policy, professional practice and inter-agency working to protect, safeguard and promote the welfare of children.


7. Consent and Confidentiality

7.1 All SCB member agencies must be aware of the need to share information on all child deaths to enable the SCB to carry out its responsibilities in this area.
7.2 All members of the CDOP are required to maintain confidentiality in respect of the children and families subject of their consideration. 
7.3 Information regarding a child will be anonymised wherever possible. However where individual cases are reviewed there may be an element of identifiable information which needs to be shared in order to properly understand the death.
7.4 Parental consent is not required for information to be passed to the designated paediatrician for unexpected deaths in childhood and the SCB CDOP co-ordinator. Persons with Parental Responsibility should be advised that the child’s death will be subject to a review in order to learn any lessons that may help to prevent future deaths of children. This must be handled sensitively. It should normally be done by the doctor confirming the child’s death to the parents and followed up with a letter. There is a SCB leaflet available to assist parents and others with Parental Responsibility in understanding the review process and how they can contribute (see Appendix 4: Model Letter for Parents and Appendix 5: Leaflet for Parents).
7.5 Members of the CDOP must sign a confidentiality agreement, including sharing and securely storing information (see Appendix 3: Confidentiality Statement) when they join the CDOP.
7.6 In no case will any team member disclose any information regarding team discussion within the CDOP outside the meeting, other than pursuant to the mandated agency responsibilities of that individual. Public statements about the general purpose of the child death review process may be made, as long as they are not identified with any specific case.


8. Professional and Family Support

8.1 Before the CDOP meets, the Chair should consider what explanatory information is sent to the child’s family (see see Appendix 4: Model Letter for Parents and Appendix 5: Leaflet for Parents).
8.2 The CDOP Chair should consider what feedback is given 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.
8.3 The CDOP Chair should ensure that information is also received and evaluated by the CDOP regarding the services and immediate support offered to families of children who have died.


9. Learning from Child Deaths

9.1 The CDOP will monitor and advise the SCB on the resources and training required locally to ensure an effective inter-agency response to child deaths.
9.2 The CDOP will identify any public health or welfare issues and report these to the SCB who will consider how best to address these and the implications for both the commissioning of services and training.
9.3 The CDOP will contribute to Off Island initiatives to identify lessons on the prevention of unexpected child deaths e.g. Confidential Enquiry into Maternal and Child Health (CEMACH).


10.  Reporting Mechanisms

10.1 The CDOP will submit an annual report to the SCB and make interim 6 monthly reports.
10.2

The SCB will:

  • Disseminate the findings and lessons to all relevant organisations;
  • Ensure that relevant findings inform the Children and Young People’s Plan;
  • Ensure that relevant findings inform single agency plans;
  • Act on any recommendations to improve policy, professional practice and inter-agency working to protect, safeguard and promote the welfare of children; and
  • Ensure that data relating to child deaths is submitted to the Quality Assurance group. 


Appendix 1: Terms of Reference

1.

Purpose

  1.1 The Child Death Overview Panel (CDOP) is a sub group of the Safeguarding Children Board and is established to review all deaths in children up to the age of 18 years that fall within the CDOP criteria – see Appendix 2: Threshold Criteria for Levels of Discussion of Cases at CDOP.
  1.2

There are two inter-related processes for reviewing child deaths (either of which can trigger a Serious Case Review):

  • To collect and analyse information about the death of every child under 18 years on the Isle of Man, with a view to:
    • Reduction in numbers of child deaths;
    • Prevention of accidents to children;
    • Identification of and understanding of patterns of childhood death;
    • Improvement in interagency practice in this very sensitive area;
    • Education of public and of professionals working with children;
    • Highlighting any matters of concern;
    • Identifying the need for a Serious Case Review. 
  • To oversee the process of conducting a rapid response by a group of key professionals to enquire into and evaluate each unexpected death of a child – for more information see Sudden Unexpected Death In Infants And Children (SUDIC) Procedure.

2.

Functions of the CDOP

  2.1

The CDOP Action Plan is based on the following functions:

  • Implementing, in consultation with Coroners, procedures and protocols that are in line with best practice 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 effective inter-agency working to protect, 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 response 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 Attorney Generals Chambers 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 SCB 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 SCB 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 SCB on the resources and training required to ensure an effective inter-agency response to child deaths;
  • Organising and monitoring the collection of data for the Quality Assurance minimum data set, and making recommendations (to be approved by SCBs) for any additional data that is required – see Appendix 6: Form A – Notification, Appendix 7: Form B and Appendix 8: Form C;
  • Identifying any public health issues and considering, with the Director(s) of Public Health, how best to address these and their implications for both the provision of services and for training;
  • Co-operating with Off Island initiatives – Confidential Enquiry into Maternal and Child Health (CEMACH) – to identify lessons on the prevention of unexpected child deaths;
  • Developing a work plan, which will be approved by the SCB;
  • Preparing an annual report for the SCB: this is responsible for publishing relevant, anonymised information. The CDOP will provide sufficient information for the SCB to disseminate the lessons to be learnt to all relevant organisations, ensuring that relevant findings inform the Children and Young People’s Plans and acting on any recommendations to improve policy, professional practice and inter-agency working to protect, safeguard and promote the welfare of children.

3.

Membership

  3.1

The Child Death Overview Panel membership is made up of Representatives as follows:

  • Health Services to include:
    • Public Health;
    • Designated Nurse;
    • Designated Paediatrician for Safeguarding;
    • Children’s Hospice.
  • Police;
  • Social Care;
  • CDOP Chair;
  • SCB Chair;
  • SCB Strategic Co-ordinator.
  3.2 Other members may be co-opted as appropriate (e.g. Fire and Rescue Services, Road Safety Partnership, Mental Health Services). Consideration may be given to a lay member.
  3.3 The Chair is accountable to the SCB Chair. Chairing arrangements to be reviewed on a two yearly basis.

4.

Accountability

  4.1 The Child Death Overview Panel will report to the SCB on a 6 monthly basis. The effectiveness of the Child Death Overview Panel will be reviewed annually.

5.

Arrangements

  5.1 The panel will meet three times a year.
  5.2 Administrative support will be provided by the Co-ordinator for the CDOP with support from the SCB Strategic Co-ordinator.


Appendix 2: Threshold Criteria for Levels of Discussion of Cases at CDOP

There are three levels or types of child death cases for the members of the Child Death Overview Panel (the CDOP) to consider.

  • Level 1

Where the child’s death is ‘anticipated / not unexpected’ and likely to be more ‘straightforward’, with no additional complicating factors. Cause of death may be reviewed briefly to learn key lessons. These are likely to be the substantial number of the deaths for review, and the majority are likely to be neonates. It is suggested that occasionally there should be a more detailed review of a random selection of some of these more ‘straightforward’ cases to look at them in more depth. The selection could be theme based on the cause of death (e.g. SUDI, cancer, congenital, other, etc.).

  • Level 2

Where there are additional, potentially avoidable factors in relation to the child’s death. The CDOP will require papers additional to the core papers. The range of types of deaths meeting level 2 are listed below (this is not exhaustive).

  • Level 3 (Serious Case Review)

Whilst it is not the business of a CDOP to re-discuss the information contained in a Serious Case Review, lessons and recommendations from any Serious Case Review need to be incorporated into the overall planning and strategy (including policy and staff development) arising from all child deaths. The Serious Case Reviews should also be included in the annual report of the CDOP. The decision to undertake a Serious Case Review is made by the Chair of the Safeguarding Children Board.

Process – All CDOP members contract to read the CDOP case papers in advance of the meeting to avoid delay in scheduled meeting time. Any glaring questions or omissions should be communicated to the CDOP Chair in advance of the meeting and if they cannot be dealt with before the meeting, the case is withdrawn and deferred to a subsequent panel with the required information / documents provided.

This process requires secure communication systems to share information in a timely way. A letter to agencies requesting information about children known to them will be sent where relevant (see Appendix 9: Request for Information Letter)

Click here to view 'Types of Cases'.


Appendix 3: Confidentiality Statement

Click here to view 'Confidentiality Statement'.


Appendix 4: Model Letter for Parents

Click here to view 'Model Letter for Parents'.


Appendix 5: Leaflet for Parents

Click here to view 'Leaflet for Parents'.


Appendix 6: Form A – Notification

Click here to view 'Form A – Notification'.


Appendix 7: Form B

Click here to view 'Form B'.


Appendix 8: Form C

Click here to view 'Form C'.


Appendix 9: Request for Information Letter

Click here to view 'Request for Information Letter'.

End