1. Child Death Overview Process Cdop.bdh@nhs.net CDOP Co-ordinator- Keri Clay

2. C hild D eath O verview P anel (C.D.O.P.) Mandatory to review all child deaths from April 1 st 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.

3. 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.

4. 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.

5. 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

6. 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

7. Child Death Overview Panel Process Every Death of a Child or infant (0-17 Years) Single Point of Contact Suspicious Death Expected Deaths Phase One 0--5 days Child Protection / Criminal Investigation Unexpected Deaths Rapid Response Meeting / Discussion Phase Two 5--7 Days Rapid Response Meeting Phase Three 8_12 Weeks Child Death Overview Panel Serious Case Review

9. 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

10. 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)

11. 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)

12. 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

13. Number of deaths reviewed for CDOP 24 th November 2009 Total deaths 17 Expected Unexpected 9 8

14. GENDER TotalEXPUNEX Male1037 Female761

15. According to age AGETotalEXPUNEX 0 – 28 dys871 28dys - 1312 2 yrs11- 5 yrs1-1 6 yrs1-1 8 yrs1-1 17 yrs2-2

16. Cause of death un extotal Accidental hanging11 Birth asphyxia 11 Chromosomal defects11 Congenital cardiac malformation22 Epilepsy11 Pre-maturity66 Malignancy 112 Infection33

17. PREVENTABILTY TOTALEXPUNEXP PREVENTABLE000 POTENTIALLY PREVENTABLE 505 NOT PREVENTABLE 1192 UNCLASSIFIED1

18. PLACE OF DEATH TotalExp Unex Local Hospital 7 5 2 Tertiary Hospital 4 3 1 Home 4 - 4 Hospice 1 1 - Abroad - - 1

19. 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

20. 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

21. 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

22. Useful web sites www.londonscb.gov.uk London Child Death Overview Panel Procedure London Rapid Response Procedure www.everychildmatters.gov.uk/ templates