Any professional confirming the fact of the child’s death should notify the designated person in the LSCB by completing Form A – The Notification of the Death of a Child.
Following notification of the death of a child, the designated person must establish which agencies and professionals have been involved with the child or family either prior to or at the time of death by contacting the lead professionals in each agency.
Form B – The Agency Report Form must then be sent by the designated person to the lead professional in each agency and to any professionals known to have been involved for completion.
Professionals receiving a Form B for completion must retrieve the agency case records for the child or other family members and complete on the form any information known to them or their organisation. The Form B must then be returned to the designated person within the requested time (usually 3 weeks) using a secure means of transfer.
If the death was an early or late neonatal death, the CMACE Perinatal Mortality Surveillance Form must also be completed and sent to the designated person and to the regional CMACE office.
When all Form Bs have been received by the designated person, the information should collated onto a single Form B, anonymised and entered onto a secure database by the designated person.
The anonymised Form Bs should be sent to all Panel members to read in advance of the meeting. Any serious questions, omissions or requests for additional information e.g. individual case records, autopsy reports, scene photographs, should be communicated to the designated person in advance of the meeting and if they cannot be dealt with before the meeting, the case may be withdrawn and deferred to a subsequent panel with the required information / documents provided.
The Panel will review each case at the Panel Meeting to consider any factors contributing to the death and any lessons to be learnt from the particular death or patterns of similar deaths in the area. For each death the Panel must:
- Classify the cause of death
- Make a decision about the preventability of the death
- Identify any modifiable factors
- Consider what recommendations to make (if any) and to whom. Recommendations will normally be directed at preventing future child deaths or improving the health and safety of children in the area, and not in respect of the individual case.
Form C – The Case Review Form is used to facilitate this discussion and to collate local and national data and record the CDOP findings.
If the Panel is unable to classify the death or to fully review it on the available information, the Panel must consider what additional information would assist the review. If necessary, the discussion of the case may be rescheduled to allow the collection of the additional information. If however, it is decided that no further learning is likely, even with additional information, the final decision should not be delayed.
Panel meetings may be dedicated to particular groups of deaths e.g. road traffic accidents, SUDI etc, so that specialists in relation to the type of death may be invited to attend the meeting to assist the review. When reviewing neonatal deaths, professionals from this specialist area, e.g. midwives and neonatal care, must be represented.
Minutes of Panel meetings must be provided to the Coroner for the local authority area.
The Panel’s recommendations must be submitted to the Local Safeguarding Children Board or any other relevant body identified by the Child Death Overview Panel. The Local Safeguarding Board will then monitor the implementation of the recommendations.
Child Death information templates