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Contents

1. Introduction
2. Notifications of a Child’s Death
3. Child Death Overview Panel

1. Introduction

The Surrey Safeguarding Children Board (SSCB) has responsibility for reviewing the deaths of all children other than still births or planned terminations that are within the law.

In order to fulfil its responsibilities it should be informed of all deaths of children, normally resident in the geographical area.

Completion of the Child Death Review Data Collection Form, CEMACH data set is the responsibility of the Consultant Paediatrician /Clinician confirming the death. This can be done in collaboration with other colleagues, Named Nurses for Safeguarding and liaison health visitors, as well as professionals from other agencies e.g. Police, Children’s Social Care. The completed form should be sent, within 2 weeks of the death, to:

• Public Health Information Services Analyst,
• Surrey Health Information Services

The Chair of the Overview Panel is responsible for ensuring that this process operates effectively.

2. Notifications of a Child’s Death

Deaths should be notified by the professional confirming the fact of the child’s death. For unexpected deaths this will be at the same time as they inform the Coroner and the designated paediatrician for unexpected deaths in childhood.

The Surrey Safeguarding Children Board (SSCB), through the Child Death Overview Panel, should be notified of all child deaths in Surrey. If this is not the area in which the child is normally resident, the designated person via the Child Death Coordinator should inform their opposite number in the area where the child normally resides. In these situations it should be decided on a case-by-case basis, which Panel should take responsibility for gathering the necessary information for a Panel’s consideration. In some cases this may be done jointly.

The notification sent to the PCT by the Registrar and ONS respectively will provide a check to ensure that all child deaths have been notified

3. Child Death Overview Panel

The Child Death Overview Panel will have a permanent core membership drawn from the key organisations represented on the Board although not all core members will necessarily be involved in discussing all cases. It should include a professional from public health as well as child health.

Other members may be co-opted to contribute to the discussion of certain types of death when they occur (for example, fire and rescue for house fires).

The functions of the Child Death Overview Panel include:

• Reviewing the available information on all child deaths of children aged up to 18 years (including deaths of infants aged less than 28 days but excluding babies who are stillborn and planned terminations of pregnancy carried out within the law) to determine whether the death was preventable. This decision should always be approved by the Chair of the CDOP;
• Implementing, in consultation with the local Coroner, local procedures and protocols which are in line with this guidance on enquiring into unexpected deaths and evaluating these together with information about all deaths in childhood;
• Collecting and collating an agreed data set and where relevant seeking information from professionals and family members;
• Meeting frequently to review and evaluate the routinely collected data and identifying lessons to be learnt or issues of concern with a particular focus on effective interagency working to safeguard and promote the welfare of children;
• Evaluating specific cases in depth, where necessary, at subsequent meetings. This may involve revisiting child deaths after the outcome of other types of investigations is known (for example, outcomes from Serious Case Reviews or criminal proceedings);
• Monitoring the appropriateness of the response of professionals to an unexpected death of a child,
• Reviewing the reports produced by the rapid response team on each unexpected death of a child, including the extent to which the team has brought together any recorded wishes and feelings of the child, making a full record of this discussion and providing the professionals with feedback on their work. 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;
• Where there is an ongoing criminal investigation, CPS must be consulted as to what it is appropriate for the Panel to be considering and what actions it might take in order not to prejudice any criminal proceedings;
• Referring to the Chair of the SSCB any deaths where, on evaluation of available information, the Panel considers there may be grounds for further enquiries, investigations or a Serious Case Review and explore why this had not previously been recognised;
• Informing the Chair of the SSCB where specific new information should be passed to the Coroner or other appropriate authorities;
• Providing relevant information to those professionals involved with the child's family, so that they in turn can convey this information to the family in a sensitive and timely manner;
• Monitoring the support and assessment services offered to families of children who have died;
• Monitoring and advising the SSCB on the resources and training required to ensure an effective inter-agency response to child deaths;
• Organising and monitoring the collection of data for the nationally agreed data set and making recommendations (to be approved by LSCBs) for any additional data to be collected locally;
• Identifying any public health issues and considering, with the Director(s) of Public Health, how best to address these and their implications for both the provision of services and for training; and
• Co-operating with regional and national initiatives e.g. the Confidential Enquiry into Maternal and Child Health (CEMACH) - to identify lessons on the prevention of child deaths.

The Child Death Overview Panel work plan will be approved by the SSCB. The will prepare an annual report for the SSCB, which will have responsibility for publishing relevant, anonymised information.

The SSCB will disseminate the lessons to be learnt to all relevant organisations, ensure relevant findings inform the Children and Young People’s Plan and act on any recommendations to improve policy, professional practice and inter-agency working to safeguard and promote the welfare of children.

End