Child Death Overview Process

Cdop.bdh@nhs.net

CDOP Co-ordinator- Keri Clay

Child Death Overview Panel (C.D.O.P.)Mandatory to review all child deaths from April 1st 2008

There are two elements to child death processes

Rapid Response Team: a group of professionals who are responsible for enquiring into and evaluating each unexpected death of a child.

Child Death Overview Panel: review of all child deaths in the Local Authority The aim is to identify any trends or patterns in these deaths. This information will be used to avoid of prevent child deaths in the future. The Child Death Overview Panel should inform local strategic panel for children's services, and policy and practice developments.

Definition

• An unexpected death

• This Procedure applies when a chid dies unexpectedly (birth up to 18th birthday, excluding babies stillborn). This includes traffic accidents, suicides and murders.

• An unexpected death is defined as the death of a child not anticipated as a significant possibility 24 hours before the death, or where there was a similarly unexpected collapse leading to or precipitating the events that led to the death.

Learning from child deaths

• The CDOP should monitor and advise the LSCB on the resources and training required locally to ensure an effective inter-agency response to child deaths.

• The CDOP should identify any strategic issues (such as public health, community safety, health and safety etc) and consider how best to address these and their implications for both the provision of services and for training.

Rapid Response Meetings (multi agency discussion)

Members

• Designated Doctor,

• Paediatric Liaison

• CDOP Coordinator / Chairperson

• Minute taker / administrator

• G.P.,

• Consultant

• Nursing staff (including community nursing staff)

• Police

• Children’s Services

Rapid Response Meetings ( multi agency discussion)

Both the Phase Two ( 5 -7 days) and Phase Three (8 -12 Weeks)meetings will consider

• Support for the family and parents and care and protection of any other children in the home

• Home visit (if necessary), initial or final Post Mortem report

• Planning consistent with any police enquiry

• Establish and clinical issues

• Refer any Child Protection or criminal issues onto relevant agencies

• Complete or update Form B’s

• Completed Form B send to CDOP for consideration

Child Death Overview Panel Process

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Child Death Overview Panel (CDOP)

Every Local Children’s Authority must now review the circumstances of all child deaths (up to 18) in their area. (N.B. not stillbirths as these will be overviewed annually)

CDOP Members

• Chairperson

• Vice Chairperson

• Designated Doctor

• Coordinator

• Police

• Children Services Representative

• Designated Nurse (Barking, Dagenham and Havering)

• Co-opted members or visitors as necessary

At the CDOP meetings Information about the death of every child is collected and reviewed via the Form B and if necessary records from;

• Ambulance• Hospital, Community Health• Schools• Police• Children’s Services• Any other relevant agencies

Child Death Overview Panel (CDOP)

The CDOP will meet on a quarterly basis ( more frequent if necessary)

Once it has considered and reviewed the reports the CDOP, if necessary makes recommendation to local agencies;

• Health Trust

• Public Health Depts.

• Children’s Services

• Police

and to agencies such as

• Fire Service and Traffic

At the end of the year the CDOP will provide an annual report to the Local Safeguarding Children’s Boards

Child Death Overview Panel (CDOP)

Purpose Of The Panel?

• Identify whether there are any patterns or trends emerging locally,

• Identify any lessons that can be learned about the patterns of child deaths locally, and

• Based on that knowledge take action to improve the safety and welfare of children in the area.

• To ensure that, where possible further deaths of children can be prevented.

• Provide a annual report based on local child deaths

Number of deaths reviewed for CDOP

24th November 2009

Total deaths

17

Expected Unexpected

9 8

GENDER

Total EXP UNEX

Male 10 3 7

Female 7 6 1

According to age

AGE Total EXP UNEX

0 – 28 dys 8 7 1

28dys - 1 3 1 2

2 yrs 1 1 -

5 yrs 1 - 1

6 yrs 1 - 1

8 yrs 1 - 1

17 yrs 2 - 2

Cause of death

Cause of death un ex total

Accidental hanging 1 1

Birth asphyxia 1 1

Chromosomal defects 1 1

Congenital cardiac malformation 2 2

Epilepsy 1 1

Pre-maturity 6 6

Malignancy 1 1 2

Infection 3 3

PREVENTABILTY

TOTAL EXP UNEXP

PREVENTABLE 0 0 0

POTENTIALLY

PREVENTABLE

5 0 5

NOT

PREVENTABLE

11 9 2

UNCLASSIFIED 1

PLACE OF DEATH

Total Exp Unex

Local Hospital 7 5 2

Tertiary Hospital 4 3 1

Home 4 - 4

Hospice 1 1 -

Abroad - - 1

• PM reports - long wait. Can not complete 8-12 w meetings

• SCR ,Inquest etc Can not complete 8-12 w meetings

• RTA & home death late notifications

• Absence of professionals involved for rapid response meetings. eg leave.

• Unable to say whether all deaths are notified

• Deaths abroad whose responsibility to investigate?

• Tertiary hospital recommendations are not communicated to GP e.g. child died of pneumococal infection because the child was not immunised after leukaemia treatment. leaflets given to the mother but GP has not received the additional vaccination schedule.

Issues

• Early diagnosis of brain tumours

• Deaths abroad

• Pre natal issues– Domestic violence– Substance misuse– Teenage mothers– Pre natal care

• Feed back to parents

• Home visits

• New templates

Issues

Recommendations

Fundoscopy for children with recurrent headache( GP Doctors)

Inform Paediatrician children 0 – 18yrs

Police to bring photographs of scene to meetings

Echo- cardiograms to be supervised by consultants

Protocol for transfer of sick children

Shared computer drives BHRUT

Guidelines for deaths abroad

Support for parents with learning difficulties by CS

Post treatment programme for immuno depressed patients ? Audit for GPs ? Audit for follow up clinics at GOSH

Useful web sites

www.londonscb.gov.uk

• London Child Death Overview Panel Procedure London

• Rapid Response Procedure

• www.everychildmatters.gov.uk/

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