Child death reviews

Child Death Review teams

Child Death Review (CDR) teams are commissioned to ensure a coordinated health response, compliant with the Government Child Death Review Statutory and Operational Guidance, for all child deaths of children (under the age of 18).

CDR teams ensure that every family has an allocated lead professional and key worker from either the CDR team or wider multiagency team who will be a point of contact for the family and professionals.

The CDR nurses will ensure that every family, no matter how their child has died, will be offered support throughout the Child Death Review process.

The Child Death Review process

The overall purpose of the child death review process is to understand how and why children die, to put in place interventions to protect other children and to prevent future deaths. The Government’s guidance on safeguarding children, Working Together to Safeguard Children, outlines two related processes for when a child dies.

These processes are:

• a ‘Rapid Response’, where a group of professionals come together for the purpose of evaluating the cause of death in an individual child, where the death of that child is unexpected, and
• a ‘Child Death Overview Panel’, that comes together to undertake an overview of all child deaths under the age of 18 years.

It is intended that these processes will:

• document and accurately establish cause of death in each individual child
•  identify patterns of death in a community so that preventable factors can be recognised and reduced
• contribute to improved multi-professional collection of medical, social and forensic evidence where relevant
•  ensure appropriate family and bereavement support is in place, and
• identify learning points for service provision, which relate to care of children.

National Child Death Mortality Database

The National Child Death Mortality Database (NCMD) national data collection and analysis system is the first of its kind anywhere in the world to record comprehensive data, standardised across the country, on the circumstances of children’s deaths.

Before the NCMD, data was held locally. Now, with data shared across England, there is potential to identify trends and introduce changes that could improve or save the lives of more children than before.

The NCMD promise to families is as outlined below.

Child Death Overview Panel

The Child Death Overview Panel (CDOP) is a multiagency panel that looks at all child deaths in a wider context than the earlier stages of the review, which would have considered the child individually. The deaths of all children under the age of 18 must be reviewed by a CDOP. CDOP usually meets eight to 10 times a year.

The panel is not given the names of any children who died or any information that might make the report identifiable; all the details are dealt with anonymously. Their main purpose is to learn from these deaths in order to try and prevent future deaths.

Although the panel will not include the professionals who were involved in the child’s death, they will receive a report from the professionals who were involved. The CDOP makes recommendations and reports about the lessons learned to those responsible at a local level. They do not produce reports about the death of individual children, but each CDOP produces an annual report which is a public document. Anyone can read the annual report, but it does not contain any details that could identify an individual child or their family.

Parents and carers are not invited to be part of the panel but may be invited to contribute any comments they might have into the review. Although individual deaths are not reported on, if there is specific learning that is identified, or a recommendation suggested at the meeting that is relevant to the child’s death then the CDR team will feed back to the family so that they are aware.

Key national documents and useful links

• Government Child Death Review Statutory and Operational Guidance
• When a baby dies | The Lullaby Trust
• What is sudden infant death syndrome (SIDS)? | The Lullaby Trust
• SUDC UK: information about sudden unexplained death in childhood, including a video about tissue sample collection
• Sands
• Child Bereavement UK
• Child Death Helpline