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Child Death Overview Panel Terms of Reference

The subgroup is accountable to the Gloucestershire Integrated Care Board and Gloucestershire County Council’s Children’s Services. It supports the Gloucestershire Safeguarding Children Partnership Executive to fulfil its statutory responsibility to review all deaths in childhood and to monitor and evaluate the effectiveness of local arrangements to safeguard and protect children.

 

1.       Purpose

Through a comprehensive and multidisciplinary review of child deaths, the Child Death Overview Panel (CDOP) aims to better understand how and why children in Gloucestershire die and use local findings to take action to prevent other similar deaths and improve the health and safety of Gloucestershire children.

 

In carrying out activities to pursue this purpose, the CDOP will meet the functions set out in Appendix 4 of the Child Death Review Statutory and Operational Guidance 2018 and chapter 6 of Working Together to Safeguard Children 2023 in relation to the deaths of any children normally resident in Gloucestershire.  Namely collecting and analysing information about each death with a view to identifying –

(i)           any case giving rise to the need for a Rapid Review/LSCPR

(ii)          any matters of concern affecting the safety and welfare of children in Gloucestershire

(iii)         any wider public health or safety concerns arising from a particular death or from a pattern of deaths in Gloucestershire

 

2.       Objectives

·    To ensure, in consultation with the local Coroner, that local procedures and protocols are developed, implemented and monitored, in line with the guidance in Working Together on enquiring into unexpected deaths.

·       To ensure the accurate identification of and uniform, consistent reporting of the cause and manner of every child death.

·      To collect and collate an agreed minimum data set of information on all child deaths in Gloucestershire and, where relevant, to seek additional information from professionals and family members.

·  To evaluate data on the deaths of all children normally resident in Gloucestershire, thereby identifying lessons to be learnt or issues of concern, with a particular focus on effective inter-agency working to safeguard and promote the welfare of children.

·   To evaluate specific cases in depth, where necessary to learn lessons or identify issues of concern.

·       To identify significant risk factors and trends in individual child deaths and in the overall patterns of deaths in Gloucestershire, including relevant environmental, social, health and cultural aspects of each death, and any systemic or structural factors affecting children’s well-being to ensure a thorough consideration of how such deaths might be prevented in the future.

·       To identify any Public Health issues and consider, with the Director of Public Health and other provider services how best to address these and their implications for both the provision of services and for training.

·  To identify and advocate for needed changes in legislation, policy and practices to promote child health and safety and to prevent child deaths.

·   To increase public awareness and advocacy for the issues that affects the health and safety of children.

·  Where concerns of a criminal or child protection nature are identified, to ensure that the Police and Coroner are aware and to inform them of any specific new information that may influence their inquiries; to notify the GSCP of those concerns and advise on the need for further enquiries under section 47 of the Children Act, or of the need for a Rapid Review/LCSPR.

· To improve agency responses to child deaths through monitoring the appropriateness of the response of professionals to each unexpected death of a child, reviewing the reports produced by the rapid response team and providing the professionals concerned with feedback on their work. 

·  To provide relevant information to those professionals involved with the child’s family so that they, in turn, can convey this information in a sensitive and timely manner to the family.

·  To monitor the support and assessment services offered to families of children who have died.

·       To monitor and advise the Statutory Child Death Partners on the resources and training required locally to ensure an effective inter-agency response to child deaths.

·    To co-operate with any regional and national initiatives – e.g. the Confidential Enquiry into Maternal and Child Health (CEMACH). Collation of data with other neighbouring CDOPs across the region – in order to identify lessons on the prevention of child deaths.

 

3.       Scope

The CDOP will gather and assess data on the deaths of all children from infancy where the baby has shown signs of life (but excludes live born terminations and babies who are stillborn) to all children and young people less than 18 years of age who are normally resident in Gloucestershire.  This will include neonatal deaths, expected and unexpected deaths in infants and in older children.  Where a child normally resident in another area dies within Gloucestershire, that death shall be notified to the CDOP in the child’s area of residence.  Similarly, when a child normally resident in Gloucestershire dies outside Gloucestershire the Gloucestershire CDOP should be notified.  In both cases an agreement should be made as to which CDOP (normally that of the child’s area of residence) will review the child’s death and how they will report to the other.

 

Team Membership

The Child Death Overview Panel will have a permanent core membership drawn from the following key organisations:

·       Consultant in Public Health

·       Designated Consultant Paediatrician

·       Designated Safeguarding Nurse

·       Coroner’s Office

·       Midwifery

·       Lay representative

·       Children’s Social Care

·       Police Child Protection Unit

·       Bereavement Professional

·       University Academic

·       Administration Support

·       Not mentioned health providers – GHT/GHC/SWAST/Primary care

 

 

CDOP core members will nominate a suitable deputy who will attend meetings in the absence of core members.

 

Other members may be co-opted to contribute to the discussion of certain types of death when they occur:

·       Emergency Department medical and nursing staff

·       Primary Care

·       Other paediatric input

·       Obstetric staff

·       Other Police representatives including accident investigators

·       Fire Services

·       Education

·       Paediatric Pathologist

·       Child and Adolescent Mental Health Services (CAMHS)

·       Adult Mental Health Services

·       Voluntary agencies

·       Registrar of Births, Deaths, Marriages

·       Community Safety

·       Others as required

The Chair has the discretion to defer the meeting if the appropriate representatives or deputies, with relevant skill mix are not available for a meeting or there are insufficient numbers for the meeting to be held effectively.

 

4.       Confidentiality and Information Sharing

Some 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 confidentiality and information sharing.  Information is being shared in the public interest for the purposes set out in Working Together 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-opted members and observers will also be required to sign/verbally agree the confidentiality agreement.  At each meeting of the CDOP all participants will be required to acknowledge and sign the attendance sheet, confirming that they have understood the confidentiality agreement. If virtual meetings are held members will be asked to confirm their agreement at the beginning of the meeting.

 

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.

 

5.       Accountability and Reporting arrangements

The CDOP will be accountable to the ICB and GCC Statutory Child Death Partners under Child Death Review Statutory and Operational Guidance (England) 2018.

 

The Child Death Overview Panel is responsible for ensuring the child death review team is held to account for the thorough review of all child deaths. CDOP will develop and approve its workplan  and ensure that an annual report is produced in keeping with the Child Death Review Statutory and Operational Guidance (England) 2018 for the GSCP.

 

The CDOP takes responsibility for disseminating the lessons to be learnt to all relevant organisations and acts on any recommendations to improve policy, professional practice and inter-agency working to safeguard and promote the welfare of children.

 

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

 

The CDOP will also provide data to the National Child Mortality Database (NCMD) on a regular basis via eCDOP.

 

6.       Frequency of Meetings

The CDOP will in general meet at 2 monthly intervals but may hold extra meetings if matters are identified by the Chair of the panel or Chair of the Executive which require an earlier response.

 

7.       Administration

·       Meetings will be supported by the Child Death Review Coordinator and documents and minutes will be circulated 7 days prior to the next meeting.

·       The Chair of the CDOP will ensure co-ordination with other working groups and will facilitate an annual review of these terms of reference and other associated documentation, amending as necessary.

 

 

 

 

Next review date for this document September 2025