9.4.2 Child Death Overview Panel - Terms of Reference

This was agreed in April 2008.

Purpose
Objectives
Scope
Team Membership
Confidentiality and Information Sharing
Accountability and Reporting Arrangements

1. Purpose:

Through a comprehensive and multidisciplinary review of child deaths, Worcestershire Safeguarding Children Board’s Child Death Overview Panel (CDOP) aims to better understand how and why children in Worcestershire die and to use these findings to take action to prevent child deaths and improve the health and safety of our children and young people.

In carrying out its activities the CDOP will meet the requirements set out in Chapter 7, Paragraph 7.4, Working Together to Safeguard Children 2010, in relation to the deaths of any children normally resident in Worcestershire. This includes collecting and analysing information about each death with a view to identifying:

Any case giving rise to the need for a Serious Case Review not previously identified.
Any matters of concern affecting the safety and welfare of children in Worcestershire.
Any wider health, public health or safety concerns arising from a particular death or from a pattern of deaths in Worcestershire.

2. Objectives:

To ensure, in consultation with the local Coroner, that local procedures and protocols are developed, implemented and audited, in line with the guidance in Chapter 7 of Working Together 2010.
To ensure the accurate identification of, and consistent reporting of the cause and manner of every child death.
To collect and collate an agreed minimum data set on all child deaths in Worcestershire and, where relevant, to seek additional information from professionals and family members.
To evaluate data on the deaths of all children normally resident in Worcestershire, thereby identifying lessons to be learnt or issues of concern, with a particular focus on services provided to children and young people and effective inter-agency working to safeguard and promote the welfare of children.
To evaluate specific cases in depth and, where necessary, to learn lessons or identify issues of concern and take appropriate action.
To analyse the relevant environmental, social, health and cultural aspects of each death and to identify significant risk factors and/or trends and any systemic or structural factors affecting children’s well-being to ensure thorough consideration of how such deaths might be preventable.
To identify any public health issues and consider with the Director of Public Health and other service providers how best to address these and the implications for services and training.
To identify and advocate for necessary changes in legislation, policy and practice to promote child health and safety and to prevent child deaths.
To increase public awareness of the issues that affect the health and safety of children
Where concerns of a criminal or child protection nature are identified;

To ensure that the police and coroner are aware and inform them of any specific new information that may influence their inquiries;

To notify the Chair of the LSCB of these concerns and advise the Chair on the need for further enquiries under section 47 of The Children Act 1989, or of consideration of the need for a Serious Case Review
To improve agency responses to child deaths by reviewing the reports produced by the Rapid Response Team and monitoring the efficacy of the response of professionals to each unexpected death of a child.
To have arrangements in place for providing information and feedback about the process to parents/carers.
To monitor the support and assessment services offered to families of children who have died
To monitor and advise the LSCB on the resources and training required locally to ensure an effective inter-agency response to child deaths.
To establish a process for reviewing the response by WSCB/individual agencies to recommendations made by CDOP.
To agree the Annual Report for presentation to WSCB and for wider public dissemination.
To co-operate with any regional and national initiatives, e.g. the Confidential Enquiry into Maternal and Child Health (CEMACH), in order to identify lessons on the prevention of child deaths.

3. Scope:

The CDOP will gather and assess data on the deaths of all children and young people from birth (excluding those babies who are stillborn) up to the age of 18 years who are normally resident in Worcestershire. This will include neonatal deaths, expected and unexpected deaths in infants and in older children. The CDOP will gather and consider more detailed information on certain, specific deaths, in particular those which may have lesson for the prevention of further deaths. Such information would include:

Medical records pertaining to the admission associated with the death, plus other medical notes, including discharge summaries from previous admissions.

Post mortem report and information available from the Coroner.
Report from the Rapid Response Team where application
Report of Serious Case Review
Report from review of drug related death.
Children’s Services information/summary of involvement

The CDOP may undertake thematic reviews e.g. premature infants, children with life-limited conditions. In some instances the Panel may decide to seek an independent review of a child’s death.

Where a child who is normally resident in another area dies within Worcestershire, that death shall be notified to the CDOP in the child’s area of residence. Similarly, when a child normally resident in Worcestershire dies outside the home area, Worcestershire’s CDOP should be notified. In both cases an agreement should be made as to which CDOP (normally that of the child’s area of residence) will review the child’s death and how they will report to the other.

4. Team Membership:

The Child Death Overview Panel will have a permanent core membership drawn from the key organisations represented on the LSCB. Other members may be co-opted to contribute to the discussion of certain types of deaths e.g. suicide, drug related deaths.

Regular attendance at the Panel meetings is essential and it will prove difficult for the Panel to function effectively unless the following agencies are represented: Police, PCT, Public Health, Acute Trust, Coroner’s Officer and Children’s Services.

5. Confidentiality and Information Sharing:

Information discussed at the CDOP meetings will not be anonymised prior to the meeting. It is therefore essential that all members adhere to strict guidelines on confidentiality and information sharing. Information is being shared in the public interest for the purposes set out in Working Together to Safeguard Children 2010 and is bound by legislation on data protection.

CDOP members will all be required to sign a Confidentiality Agreement before participating in the CDOP. Any co-opted members and observers will also be required to sign the Confidentiality Agreement. At each meeting of the CDOP all participants will be required to sign an Attendance Sheet, confirming that they have understood and signed the confidentiality agreement.

Any reports, minutes and recommendations arising from the CDOP will be fully anonymised and steps taken to ensure that no personal information can be identified.

6. Accountability and Reporting Arrangements

The CDOP will be accountable to the Chair of the Local Safeguarding Children Board.

The Child Death Overview Panel is responsible for developing its work plan, which should be approved by the LSCB. It will prepare an Annual Report for the LSCB, which is responsible for publishing anonymised information.

The LSCB takes responsibility for:

Disseminating the lessons to be learnt to all relevant organisations
Ensuring that relevant findings inform the local Children and Young People’s Plan
Acting on any recommendations to improve policy, inter-agency working and professional practice to safeguard and promote the welfare of children.

The LSCB will supply data regularly on every child death as required by the Department for Children, Schools and Families to bodies commissioned by the Department to undertake and publish nationally comparable, anonymised analyses of these deaths.

End