Child Death Reviews


Pan-Dorset Safeguarding Children Partnership

Local Guidance in relation to this chapter can be found in Child Death.

Also see: Further Information.

Working Together to Safeguard Children defines an unexpected death "as the death of an infant or child which was not anticipated as a significant possibility for example, 24 hours before the death; or where there was an unexpected collapse or incident leading to or precipitating the events which lead to the death."

The designated paediatrician responsible for unexpected deaths in childhood should be consulted where professionals are uncertain about whether the death is unexpected. If in doubt, the processes for unexpected child deaths should be followed until the available evidence enables a different decision to be made.

The Local Safeguarding Children Boards Regulations 2006 require SCPs to put in place the following functions:

  1. Collecting and analysing information about each death with a view to identifying:
    1. Any case giving rise to the need for a review mentioned in regulation 5(1)(e);
    2. Any matters of concern affecting the safety and welfare of children in the area of the authority;
    3. Any wider public health or safety concerns arising from a particular death or from a pattern of deaths in the area.
  2. Putting in place procedures for ensuring that there is a co-ordinated response by the authority, their Board partners and other relevant persons to an unexpected death.

Each death of a child is a tragedy and enquiries should keep a balance between the forensic and medical requirements and supporting the family at a difficult time. The purpose of the child death review is to help prevent such child deaths in the future and professionals supporting the parents and family members should assure them that the objective of the child death review process is not to allocate blame, but to learn lessons.

In order to do this the SCP is required to have a Child Death Overview Panel (CDOP) which is responsible for reviewing the available information on all child deaths. The membership of the panel must be drawn from the key agencies represented on the Board, but it may co-opt other relevant practitioners as and when required.

In reviewing the death of each child, the CDOP:

  • Will review all child deaths, excluding those babies who are stillborn and planned terminations of pregnancy carried out within the law;
  • Collect relevant information on each child from professionals and, where appropriate, family members;
  • Discuss each child's case and provide information to professionals who are directly involved with the family so that this information can be conveyed sensitively to the family;
  • Determine whether the death was deemed preventable, that is, those deaths in which modifiable factors may have contributed to the death and decide what, if any, actions could be taken to prevent such deaths for the future;
  • Consider any modifiable factors, for example, in the family environment, parenting capacity or service provision, and consider what action could be taken locally and what action could be taken at a regional or national level;
  • Identify when a suspicion arises that neglect or abuse may have been a factor in the child's death, the CDOP panel will notify the SCP to decide whether a Serious Case Review is required.

The local Protocol includes arrangements and contacts for notifications to the relevant agencies. Any person notifying the designated person in the SCP of the death of a child should provide as much detail as is known to them in relation to the child and family and the circumstances of the death. They should inform the designated person of any professionals known to be involved with the child or family.