Child Deaths

Child Death Reviews

Child Death Review (CDR) is the process to be followed when responding to, investigating, and reviewing the death of any child under the age of 18, from any cause. It runs from the moment of a child’s death to the completion of the review by the Child Death Overview Panel (CDOP). The process is designed to capture the expertise and thoughts of all individuals who have interacted with the case to identify changes that could save the lives of children.

The death of a child is a devastating loss that profoundly affects bereaved parents as well as siblings, grandparents, extended family, friends, and professionals who were involved in caring for the child in any capacity. Families experiencing such a tragedy should be met with empathy and compassion. They need clear and sensitive communication. They also need to understand what happened to their child and know that people will learn from what happened. The process of expertly reviewing all children’s deaths is grounded in deep respect for the rights of children and their families, with the intention of preventing future child deaths.

How to notify us of a child death

To notify us of the death of a child within Surrey please follow the link below to complete your Notification Form within 24hrs.

Surrey eCDOP Notification Form A

On submission of your Notification, our CDR Team will be alerted and will be able to view the Form. The Form will also automatically be shared with the National Child Mortality Database (NCMD).

If you have any problems with submitting a notification via the above link please contact CDOP Co-ordinator on Tel: 07818 046748 or email syheartlandsccg.surreycdop@nhs.net

Professionals required to complete a Form B will be contacted directly by our CDR Team via eCDOP.

Purpose of a Child Death Review (CDR)

Under the Children Act 2004, as amended by the Children and Social Work Act 2017, the two child death review partners (local authorities and clinical commissioning groups) must set up child death review arrangements to review all deaths of children normally resident in the local area and, if they consider it appropriate, for any non-resident child who has died in their area.  In accordance with the statutory guidance Working Together to Safeguard Children (2023) Child death review partners must make arrangements for the analysis of information from all deaths reviewed. The purpose of a review and/or analysis is to identify any matters relating to the death, or deaths, that are relevant to the welfare of children in the area or to public health and safety, and to consider whether action should be taken in relation to any matters identified. If child death review partners find action should be taken by a person or organisation, they must inform them.

Joint Agency Response (JAR):

A JAR is a coordinated multi-agency response by the named nurse, police investigator, duty social worker and should be triggered if a child dies:

is or could be due to external causes;
is sudden and there is no immediately apparent cause (including sudden unexpected death in infancy/childhood (SUDI/C);
occurs in custody, or where the child was detained under the Mental Health Act;
where the initial circumstances raise any suspicions that the death may not have been natural; or
in the case of a stillbirth where no healthcare professional was in attendance.

All deceased children that meet the criteria for a JAR should be transferred to the nearest appropriate Emergency Department (ED) to enable the JAR to be triggered. A JAR should also be triggered if such children are brought to hospital near death, are successfully resuscitated, but are expected to die in the following days. In such circumstances the JAR should be considered at the point of presentation and not at the moment of death, since this enables an accurate history of events to be taken and, if necessary, a ‘scene of collapse’ visit to occur.

The “Sudden and Unexpected Death in Infancy and Childhood: multiagency guidelines for care and investigation (2016)” gives comprehensive advice and expectations of all agencies involved in a JAR, and should be applied in full by all agencies. Effective cross-agency working is key to the investigation of such deaths and to supporting the family. It requires all professionals to keep each other informed, to share relevant information between themselves, and to work collaboratively.

Joint home/scene visit:

As soon as possible after the infant’s death, the named nurse and police investigator should visit the family at home or at the site of the infant’s collapse or death. The purpose of this visit is to obtain further, more detailed information about the circumstances and environment in which the infant died, and to provide the family with information and support.

This visit should normally take place within daylight hours. Unless there are clear forensic reasons to do so, the environment within which the infant died should be left undisturbed so that it can be fully assessed jointly by the police and named nurse, in the presence of the family. Following this review, the named nurse should prepare a report of the initial findings to be made available to the pathologist, the coroner and the police investigator as soon as possible, and preferably prior to the post-mortem examination.

The Post-mortem examination:
The aim of the investigation is to establish, as far as is possible, the cause of death. The investigation will concentrate not just on the infant, but will consider the family history, past events, and the circumstances. These factors can be helpful in determining why an infant died. All parts of the process should be conducted with sensitivity, discretion and respect for the family and the infant who has died. Once the results of the PM and other clinical investigations are known, the Child Death Review Meeting (CDRM) is arranged to review emerging findings. The CDRM should ideally take place before the inquest so as to inform the coroner’s investigation.

Child Death Review Meeting (CDRM)

This is a multi-professional meeting where all matters relating to an individual child’s death are discussed by the professionals directly involved in the care of that child during life and their investigation after death.

The nature of this meeting will vary according to the circumstances of the child’s death and the practitioners involved. A member of the child death review team will attend all appropriate CDRMs in the acute and community settings. They will represent the ‘voice’ of the parents at these professional meetings, ensure that their questions are effectively addressed, provide feedback to the family afterwards and also ensure outputs from CDRMs (draft Analysis Forms) are shared with CDOP panel.

Child Death Overview Panel (CDOP)

This is a multi-agency panel set up by Child death review (CDR) partners to review the deaths of all children normally resident in their area, and, if appropriate and agreed between CDR partners, the deaths in their area of non-resident children, in order to learn lessons and share any findings for the prevention of future deaths. This review should be informed by a standardised report from the CDRM, and ensures independent, multi-agency scrutiny by senior professionals with no named responsibility for the child’s care during life.

Family engagement and Bereavement support

Every family has the right to have their child’s death sensitively reviewed to, where possible, identify the cause of death and to ensure that lessons are learnt that may prevent further children’s deaths. Professionals have a duty to support and engage with families at all stages in the review process. Parents and carers should be informed about the review process and given the opportunity to contribute to investigations and meetings and be informed of their outcomes.

The processes that follow the death of a child are complex, in particular when multiple investigations are required. Recognising this, all bereaved families will be given a Child Death Review Nurse who will fulfil the role of single, named point of contact to whom they can turn for information on the child death review process, and who can signpost them to sources of support. Families should expect to be able to contact the child death review nurse during normal working hours. The leaflet When a Child Dies – A Guide for Parents and Carers should be given in printed format to all bereaved families or carers

Links to Annual Report

Please see the SSCP Annual Report, which includes CDOP recommendations for learning and preventing child deaths in Surrey.

Link to Parents leaflets

CDOP resources

CDOP Learning