Child Death Review Process
What is the Child Death Overview Panel?
The Child Death Overview Panel (CDOP) is the statutory body responsible for reviewing the deaths of all children and young people under 18 who were normally resident in Gloucestershire, regardless of where the death occurred. CDOP is legally required to carry out a child death review whenever a child dies, to understand how and why children die and to identify whether any lessons can be learned locally or nationally.
The child death review process has two parts:
A rapid response from key professionals who come together to enquire into and evaluate every unexpected child death.
A detailed case review for every child death, followed by an anonymous overview of all deaths within the Gloucestershire area, undertaken by the CDOP.
The Role of CDOP in Gloucestershire
In Gloucestershire, the CDOP plays a vital role in coordinating information, reviewing circumstances surrounding each child’s death, and identifying any modifiable factors that could help prevent future deaths. The review process also supports families, schools, and professionals by helping them understand the circumstances of a child’s death and ensuring appropriate bereavement support is available.
When a child dies, the death must be reported to the Gloucestershire CDOP through the online notification process. CDOP then gathers information from agencies involved in the child’s life to form a comprehensive understanding of what happened and what may need to change.
What to do in the Event of a Child Death
Child Death Review Published Arrangements (Protocol) 2024
The deaths of all babies / children under 18 years (excluding live born terminations) resident in Gloucestershire, regardless of where the death took place, should be notified to the Gloucestershire Safeguarding Children Partnership using the online Notification Form (click button below).
Notification Form to Report a Child Death
Deaths of children not normally resident in the Gloucestershire area and who die here should also be notified using this link. This information will be passed onto the relevant CDOP Panel who will then coordinate the information.
All Local Safeguarding Children Partnerships have a statutory duty to hold a review whenever a child dies.
The Child Death Review (CDR) process is designed to ensure Local Safeguarding Children Partners are in a position to learn any lessons there might be from the death of a child or young person. Further it is understood that when a child dies those left grieving; parents, siblings, other family members, friends and acquaintances, will need extra support and a good understanding as to what caused the loss of their loved one. The child death review process is designed to help with providing the appropriate support to families and schools to gain information about why children die. There are two aspects to a CDR.
- A rapid response by a group of key professionals who come together for the purpose of enquiring into and evaluating each unexpected death of a child.
- A final case review for every child death
- An anonymous overview of all child deaths in the Gloucestershire Safeguarding Children Partnership area, undertaken by a panel.
For advice and information please contact the Child Death Review Team by email at cdop@gloucestershire.gov.uk
For advice about how to support pupils and members of staff following a child death at an educational setting please contact Georgina Summers, Safeguarding in Education Manager by email at gsep@gloucestershire.gov.uk
Child Death Overview Panel – Annual Reports
Each year, Gloucestershire’s Child Death Overview Panel (CDOP) reviews the circumstances of all child deaths in the county to identify learning, reduce risks, and improve the wellbeing of children and families. The annual reports below summarise key findings, themes, and recommendations that support safeguarding partners in preventing future tragedies.
2024 - 2025 Gloucestershire CDOP Annual Report
2023 - 2024 Gloucestershire CDOP Annual Report
2022 - 2023 Gloucestershire CDOP Annual Report
2021 - 2022 Gloucestershire CDOP Annual Report
2020 - 2021 Gloucestershire CDOP Annual Report
ICON – Infant Crying Advice and Support
The ICON resources provide clear, practical guidance for parents and carers on coping safely with infant crying. These materials help professionals share consistent messages that support families, reduce stress, and promote safer responses when caring for babies. Access the documents below for tools, leaflets, and training resources used across Gloucestershire.
Useful Information and Documents
This section brings together key guidance, forms, and reference materials to support professionals involved in Gloucestershire’s child death review process. These documents provide practical information to help partners understand their responsibilities, follow established procedures, and contribute effectively to the learning that helps protect children and prevent future deaths.
Working Together to Safeguard Children
SWAST Guidance for schools on calling 999
Information for Parents, Families and Carers Leaflet
Notification of a Child Death Link (Poster)
eCDOP - How to make a Notification of a Child Death