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8.2 Child Death Overview Panel


This chapter was updated in August 2014. Section 8, Duties and Powers of Coroners was added in line with the Coroners and Justice Act 2009, Coroners (Inquests) Rules 2013 and Coroners (Investigations) Regulations 2013.


  1. Purpose of the Child Death Overview Panel
  2. Functions of the Child Death Overview Panel
  3. Accountability of the Child Death Overview Panel
  4. Administration of the Child Death Overview Panel
  5. Membership of the Child Death Overview Panel and the Role of Partner Agencies
  6. Duties of the CDOP Manager
  7. Confidentiality and Information Sharing
  8. Duties and Powers of Coroners
  9. Child Protection Concerns
  10. Taking Action to Prevent Child Deaths
  11. Working with the Media

1. Purpose of the Child Death Overview Panel

Through a comprehensive and multidisciplinary review of child deaths, the Child Death Overview Panel (CDOP) aims to improve the understanding of how and why children in Wirral die; and use the findings to take action to prevent future child deaths and more generally to improve the health and safety of the children in the area.

In carrying out activities to pursue this purpose, the CDOP will meet the Local Safeguarding Children Board (LSCB) functions, as set out in paragraph 6 the Local Safeguarding Children Boards Regulations 2006 and Chapter 5: Child Death Reviews, Working Together to Safeguard Children March 2015 in relation to the deaths of any children normally resident in the area:

  1. Collecting and analysing information about each child's death with a view to identifying: (i) any case giving rise to the need for a review mentioned in regulation 5(1)(e); (ii) any matters of concern affecting the safety and welfare of children in the area of the authority; and (iii) any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area;
  2. Establishing procedures for ensuring a coordinated response to an unexpected child death.

The Panel will review deaths of all children aged 0-18 (excluding stillbirths) normally resident in the Wirral area.

Where the Panel is made aware of the death of a child in their area who would normally be resident in another Local Authority area, or the death of a child in another area who would normally be resident in Wirral, the Panel manager will liaise with his/her opposite number in the other Local Authority area to ensure both Panels are notified of the death, and to determine which Panel is best placed to carry out a review of that child's death.

2. Functions of the Child Death Overview Panel

The Child Death Overview Panel will:

  • Meet regularly to complete a multi-agency evaluation of all child deaths in their area;
  • Where appropriate undertake a detailed and in-depth evaluation into specific cases, including all unexpected deaths, assessing all relevant social, environmental, health and cultural aspects, or systemic or structural factors of the death, along with the appropriateness of the professionals' responses to the death and involvement before the death, in order to complete a thorough consideration of whether and how such deaths might be prevented in future;
  • Collect and collate information using the templates on the Child Death Data Collection Guidance (Gov.uk) and where relevant seek further information from professionals and family members;
  • Evaluate data on the deaths of all children normally resident in the area, thereby identifying local lessons to be learnt and issues of concern, with a particular focus on effective inter-agency working to safeguard and promote the welfare of children;
  • Identify and report any local Public Health issues and consider, with the Director(s) of Public Health and other provider services how best to address these and their implications for both the provision of services and for training;
  • Identify and advocate for needed changes in legislation, policy and practices, or public awareness, to promote child health and safety and to prevent child deaths;
  • Ensure concerns of a criminal or child protection nature are shared with the police, Children's Specialist Services and the Coroner;
  • Ensure any case identified as meeting criteria for a Serious Case Review are referred to the chair of the LSCB;
  • Provide information to professionals involved with families so that this can be passed on in a sensitive and timely manner;
  • Implement, review and monitor the local procedures for rapid response arrangements - see SUDI Protocol;
  • Monitor the quality of information, support and assessment services to families of children who have died;
  • Cooperate with any regional and national initiatives in order to identify lessons on the prevention of child deaths;
  • Increase public awareness and advocacy for the issues that affect the health and safety of children; and
  • Monitor and advise the Local Safeguarding Children Board on the resources and training required locally to ensure an effective inter-agency response to child deaths.

3. Accountability of the Child Death Overview Panel

The Child Death Overview Panel will be responsible, through its chair, to the chair of the Local Safeguarding Children Board.

The Panel will provide to the LSCB and all constituent agencies, an annual report (in which all information should be aggregated and anonymised) which shall be a public document. In addition, the Panel will report to the LSCB any matters of concern arising from the course of its work as set out above. The LSCB will take responsibility for disseminating the lessons to be learnt to all relevant organisations; ensuring that relevant findings inform the Children and Young People's Plan; and acting on any recommendations to improve policy, professional practice and inter-agency working to safeguard and promote the welfare of children.

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

4. Administration of the Child Death Overview Panel

The Panel will be chaired by the Chair of the LSCB or his/her representative. The Chair of the Overview Panel is responsible for ensuring that this process operates effectively.

The work of the Panel will be co-ordinated by the Panel Manager, supported by a clerical assistant (see Section 6, Duties of the CDOP Manager).

CDOP meetings will be held every 6-8 weeks.

5. Membership of the Child Death Overview Panel and the Role of Partner Agencies

Each partner agency of the LSCB will identify a senior person within their organisation who has responsibility for representing the agency on the CDOP. Each agency will ensure their representative is allocated sufficient time in their job plan to attend all Panel meetings, having prepared in advance of the meetings, and is able to report back to the agency any specific recommendations arising from the panel.

Partner agencies will ensure that staff in their agency who become aware of the death of a child will report that child's death to the Panel.

Partner agencies will ensure that relevant staff are made aware of the child death review functions of the LSCB and are able to access appropriate training.

6. Duties of the CDOP Manager

The CDOP manager will be responsible for the smooth running of all child death review processes. They will:

  • Ensure and monitor the effective running of the notification, data collection and storage systems;
  • Determine meeting dates and send meeting notices to team members;
  • Obtain names and compile the summary sheet of child deaths to be reviewed and distribute to team members two to three weeks prior to each meeting;
  • Ensure that notifications of child deaths are available for team review;
  • Ensure that new members receive an orientation to the Panel prior to their first meeting;
  • Ensure that all new CDOP members, ad hoc members and observers sign a confidentiality agreement;
  • Encourage the sharing of information for effective case reviews;
  • Chair the CDOP meetings encouraging all team members to participate appropriately, ensure that all statutory requirements are met, and maintain a focus on preventive work;
  • Facilitate resolution of agency disputes;
  • Compile and disseminate notes from each CDOP meeting;
  • Complete and submit an annual report to the LSCB;
  • Monitor the outcome of recommendations and prevention initiative and activities.

7. 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 Information Sharing and Confidentiality. Information is being shared in the public interest 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 ad-hoc or co-operated 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.

8. Duties and Powers of Coroners


The Coroners (Investigations) Regulations 2013 place a duty on coroners to inform the LSCB, for the area in which the child died or the child’s body was found, where the coroner decides to conduct an investigation or directs that a post mortem should take place. The coroner must provide to the LSCB all information held by the coroner relating to the child’s death. 

Where the coroner makes a report to prevent other deaths, a copy must be sent to the LSCB.
8.2 On receipt of an initial report of a death of a child, the LSCB with an interest in this information should inform the coroner of the address(es) (including email address(es)) to which future information should be supplied. If any information comes to the attention of an LSCB which it believes should be drawn to the attention of the relevant coroner, then the LSCB should consider supplying it to the coroner as a matter of urgency.

9. Child Protection Concerns

Where there is an ongoing criminal investigation, the Crown Prosecution Service must be consulted as to what it 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, discussions should take place with Wirral Children's Specialist Services. It may be decided that it is appropriate to initiate a Social Work Assessment of Needs and Strengths 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 procedures for Managing Individual Cases set out in Part 3 of this manual should be followed. 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 the LSCB should be informed of the case to ensure that appropriate procedures are followed and to consider the need for a Serious Case Review.

10. 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 (taking account of 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 Organisational Practices where system failures are identified, or models of good practice highlighted;
  6. Mobilising 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, measureable actions, and will include plans for monitoring implementation.

11. Working with the Media

Media interest in the work of the CDOP or in individual cases will be dealt with by the press officer for the LSCB. 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 LSCB press officer will work proactively with the media to promote the work of the CDOP alongside that of the LSCB in safeguarding and promoting the welfare of children in the Wirral Local Authority area.