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The death of a child is a tragedy, and subsequent enquiries / investigations should keep an appropriate balance between forensic and medical requirements and the family’s need for support.
Statutory Safeguarding Responsibilities for Child Death Reviews
Statutory guidance Working Together to Safeguard Children 2026 defines child death review partners as “local authorities and any Integrated Care Boards (ICBs) for the local area as set out in the Children Act 2004, as amended by the Children and Social Work Act 2017″.
When a child dies, in any circumstances, it is important for parents and families to understand what has happened and whether there are any lessons to be learned.
The responsibility for ensuring child death reviews are carried out is held by ‘child death review partners,’ as defined within Working Together to Safeguarding Children 2026 and set out in current legislation.
Child death review partners must make arrangements to review all deaths of children normally resident in the local area and, if they consider it appropriate, for any non-resident child who has died in their area. Child death review partners for two or more local authority areas may combine and agree that their areas be treated as a single area for the purpose of undertaking child death reviews.
Child death review partners in Bournemouth, Christchurch, Poole, Dorset and Somerset have agreed to treat Pan Dorset and Somerset as a single area, resulting in a joint Pan Dorset and Somerset Child Death Overview Panel (CDOP) undertaking child death reviews for Bournemouth, Christchurch, Poole, Dorset and Somerset children.
Below is the Memorandum of Understanding that the Child Death Partners have all signed up to, which outlines the new child death arrangements, along with a Terms of Reference for the joint Pan Dorset and Somerset CDOP. The new arrangement came into force in July 2019.
The accountable officials for the Child Death Review partners in Bournemouth, Christchurch, Poole, Dorset and Somerset are as follows:
| Name of Accountable Officer | Organisation |
| Jonathan Higman, Chief Executive | Somerset ICB |
| Duncan Sharkey, Chief Executive | Somerset Council |
| Tim Goodson, Accountable Chief Officer | Dorset ICB |
| Graham Farrant, Chief Executive | Bournemouth, Christchurch and Poole Council |
| Catherine Howe, Chief Executive | Dorset Council |
Executive officers for all Child Death Review Partner agencies, with delegated authority from the accountable officers listed above, have signed the Memorandum of Understanding and approved the CDOP Terms of Reference.
The Designated Doctors for child death in Dorset and Somerset ICB are as follows:
| Name of Designated Doctor Child Death | Organisation |
| Dr Thomasina Nicole | Somerset ICB |
| Dr Christopher Knight | Somerset ICB |
| Dr Abigail Deketelaere | Dorset ICB |
| Dr Ann Dewar | Dorset ICB |
Pan Dorset and Somerset Child Death Review Partner’s Memorandum of Understanding and Child Death Overview Panel Terms of Reference [2]
The Child Death Overview Panel
The Panel is responsible for reviewing the death of all children from birth (not including stillbirths) up to but not including the age of 18 years.
The panel also has membership from Designated Paediatric Consultants, Specialist Nurses, Local Authority and NHS Children’s Safeguarding Managers, Dorset Police, South Western Ambulance Service and the Dorset Coronial Service.
The Panel will seek to:
- understand the reasons for each child’s death
- address the possible needs of other children in the household
- address the needs of all family members
- consider any lessons to be learnt about how to prevent the death of a child
Purpose of Child Death Reviews:
The Pan Dorset Child Death Overview Panel (CDOP) is responsible for collecting and analysing information about each death with a view to identifying:
- any case giving rise to the need for a Serious Case Review
- any matters of concern affecting the safety and welfare of children; and
- any wider public health concern arising from a particular death or from a pattern of deaths
- putting into place procedures for ensuring that there is a co-ordinated response to all deaths
Unexpected Deaths – Rapid Response Procedure
An unexpected death is defined as the death of an infant or child which was not anticipated as a significant possibility i.e. 24 hours before the death or where there was a similarly unexpected collapse leading to or precipitating the events which led to the death.
Whenever an unexpected death of a child occurs, a multi-agency response is initiated including a lead Consultant Paediatrician, a Dorset Police Senior Investigating Officer, A & E staff, ambulance staff, GPs, social care, health visitors and the Coroner to enquire into the circumstances.
A decision will be made as to which professional will take the lead. This would be the police where there are apparent suspicious circumstances or other external factors. The lead Paediatrician would usually take the lead where there are apparent health or medical factors which have resulted in the death of the child.
In addition to establishing the precise cause of death, immediate care and support will be provided to the parents or carers and other family members. The CDOP will be responsible for monitoring the appropriateness of the response of professionals to an unexpected death of a child.
Data Collection and Analysis
The Department for Education (DFE) coordinates the national data gathering procedures for every child who dies and publishes a set of templates for use by CDOPs to facilitate and standardise the local, regional and national data collection process.
The Panel will categorise the “preventability” of the death according to whether there were modifiable factors present.
- Preventable – where a death could have been prevented if a particular action(s) had been taken
- Potentially preventable – where there are potentially modifiable factors extrinsic to the child
- Not preventable – the death was caused by intrinsic or extrinsic factors, with no modifiable factors
The Panel will identify any emerging learning points and record its recommendations which will be reported to the respective LSCB for consideration of appropriate action. Typically this might be the initiation of a public health awareness message, the launch of a specific campaign or working with partner agencies to improve the effectiveness or quality of their processes or procedures.
The Child Death Review process requires a number of statutory forms, these are:
- Form A – Child Death Notification Form. Completed by any agency involved in the death of a child and forwarded to the CDOP Administrator
- Form B – Child Death Review Reporting Form. Completed by any professional who treated the child or who had contact with the child or family before the death. Additional reporting forms are used to collect more specific data relating to neonatal deaths, known life-limiting conditions, sudden unexpected deaths in infancy, road traffic accidents, drowning, fire / burns, poisoning, other non-intentional injury, substance misuse, apparent homicide, apparent suicide and a summary of autopsy findings.
- Form C – Child Death Analysis Form. The CDOP Administrator will summarise the collective agency reports which will be presented to the Panel whose members will consider relevant environmental, extrinsic, medical or personal factors which may have contributed to the child’s death.
The Child Death Review Process is co-ordinated by Somerset on behalf of the Pan-Dorset area.
For any further information about the Pan Dorset Child Death Overview Panel or the child death review process, please contact: somicb.somersetchilddeath@nhs.net [3]
The following documents will be of relevance:
- Pan-Dorset Child Death Protocol V3.1 [4]
- CDOP Guidance October 2018 [5]
- CDOP Pan Dorset Rapid Response Flowchart V3 [6]
- Pan Dorset CDOP Flowchart Apr 2019 [7]
- When a Child Dies a Guide for Parents and Carers [8]
- Bereaved Parents Leaflet [9] – the Dorset Safeguarding Children Partnership have also collated a directory of local and national bereavement support services [10] which parents and carers can be signposted to
- Safe Sleeping Leaflet [11]
- Preventing Childhood Deaths Guidance [12]
- Cultural Awareness for when a Child Dies [13]
- Child Drowning – Safety Warning for Health and Care Professionals [14]