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Contents

1. Core Functions of the Child Death Overview Panel
2. Child Protection Concerns
3. Taking action to prevent child deaths
4. Working with the media

1. Core Functions of the Child Death Overview Panel

1. To receive notifications of the deaths of all children from birth to 18 years in Worcestershire In order to ensure complete notification.  These notifications will come from a number of sources including the Police, Ambulance Service, Accident and Emergency Departments, Paediatricians, Primary Care Trust, Fire and Rescue service, the Registrar of Births, Deaths and Marriages, the Coroner and Acorns Hospice.  Individual professionals should notify the CDOP Administrator at the same time as they notify the Coroner (in the case of an unexpected death) or Registrar / PCT. 
2. Each death should be notified to the CDOP of the area in which the child (or mother in the case of a neonatal death) was normally resident.  If a different team (for example the CDOP for the area in which the child died) is notified, the CDOP Coordinator will notify their counterpart in the area of residence.  For deaths occurring in an area different to that of the child’s normal residence, an agreement must be reached between the two CDOPs as to which Panel will review the death (normally the CDOP for the area of residence) and how the other Panel will be notified of the outcome.
3. To collect a core data set of information relating to each child’s death.  A data collection tool will be sent to the agency, which made the notification and other key professionals.  Data returned will be entered on a secure database.  In addition to the core data set, for deaths requiring more in-depth review, further information will be sought from all involved agencies.  This may include: case summaries from health records, case information from police, social care and education; autopsy reports and results of further investigations; relevant information on the family and social circumstances; scene reports from police child abuse investigation units or accident investigators.
4. To meet on a regular basis to review specified infant/child deaths, drawing on comprehensive information from all agencies on the circumstances of the child’s death.  This information will be reviewed by the team, in order to meet the objectives set out in the Terms of Reference.  Whilst all deaths will be notified to the team and a core data set collected, not all deaths will be reviewed in detail.  Particular consideration shall be given to the review of sudden unexpected deaths in infancy and childhood; accidental deaths; deaths related to maltreatment; suicides; and any deaths from natural causes where there are potential lessons to be learnt about prevention. 
5. The team will determine, and review on a regular basis, which deaths are to be reviewed in an in-depth manner.
6. To receive reports from other reviews of child deaths, including individual reviews of SUDIC, hospital reviews of perinatal deaths and Serious Case Reviews.
7. To review annually the numbers and patterns of deaths in Worcestershire.
8. To notify the chair of WSCB, the coroner and the police of any case(s) identified where there are previously unrecognised concerns of a criminal or child protection nature.
9. To identify any lessons to be learnt from individual reviews or reviews of overall patterns and trends, including any system or process issues and any health, public health and safety issues.
10. To monitor professional responses to child deaths, and identify good practice as well as any gaps or deficiencies in the process.
11. To make appropriate recommendations to WSCB. 
12. To provide WSCB and its constituent agencies with an annual report on the work of the team.

2. Child Protection Concerns

The police and Coroner must be informed immediately that there is a suspicion of a crime or evidence comes to light that the death may be of a suspicious nature.  The Chair of WSCB should be informed of the case to ensure that appropriate procedures are followed and to consider the need for a Serious Case Review. Where there is an ongoing criminal investigation, the Crown Prosecution Service must be consulted as to when/what is appropriate for the Panel to consider and what actions it might take in order not to prejudice any criminal proceedings. 

If, during the enquiries, concerns are expressed in relation to the needs of surviving children in the family, immediate discussions should take place with Children’s Social Care. It may be decided that it is appropriate to initiate an initial assessment using the Framework for the Assessment of Children in Need and their Families (2000). If concerns are raised at any stage about the possibility of surviving children in the household being abused or neglected, the inter-agency procedures set out in Chapter 5 of Working Together should be followed.

3. Taking action to prevent child deaths

The most important reason for reviewing child deaths is to improve the health and safety of children and to prevent other children from dying.  The CDOP will maintain a focus on prevention through all its work. 

Individual deaths and overall patterns of childhood deaths will be evaluated to determine if the deaths were preventable; to identify modifiable risk factors (factors in the child, the parenting capacity, wider family, environmental and societal factors, and services provided to or needed by the child or family); and to determine the best strategy(ies) for prevention.

Strategies may be considered at different levels:

1. Strengthening Individual knowledge and skills: Assisting individuals to increase their knowledge and capacity to act, leading to behaviour change, through education, counselling and individual support.
2. Promoting Community Education
3. Training Providers to improve knowledge, skills, capacity and motivation to effectively promote prevention.
4. Fostering coalitions and networks of individuals and organisations to work for advocacy and health promotion
5. Changing organizational practices where system failures are identified, or models of good practice highlighted.
6. Mobilizing neighbourhoods and communities in the process of identifying, prioritising, planning and making changes.
7. Influencing policy and legislation where appropriate through local and national advocacy

Recommendations made by the CDOP will be based on the lessons learnt from the review of child deaths, will be focused on specific, measurable actions, and will include plans for monitoring implementation.

4. Working with the media

The annual report of the CDOP will be a public document and as such will have no identifiable information contained within.  Details of individual case discussions are to be kept confidential and in no circumstances will such details be passed to the press.  The WSCB Chair will work proactively with the media to promote the work of the CDOP alongside that of WSCB in safeguarding and promoting the welfare of children in Worcestershire. 

End