Merseyside Child Death Overview Panel (CDOP)

Child Death Overview Panels became a statutory function on 1.4.2008. The guidance for the functioning was set out in Working Together to Safeguard Children 2006, revised in 2010, 2013 and 2015. Each of the five Merseyside LSCBs set up their own CDOP that functioned until 2011.

In April 2011 four Merseyside CDOPs, Liverpool, St Helens, Sefton and Wirral merged to form Merseyside CDOP. In April 2014 Knowsley CDOP joined Merseyside CDOP.

The functions of CDOP remain the same, namely:

  1. Have an overview of the deaths of children under the age of 18 years in Knowsley, Liverpool, St Helens, Sefton and Wirral. This will include neonatal and perinatal deaths, but not stillbirths and planned terminations of pregnancy carried out within the law.

  2. Through early liaison between members of CDOP and the Critical Incident Group/Serious Case Review Group (CIG/SCRG), identify cases where the CIG group convene in line with LSCB procedures.

  3. The Panel is not concerned with blame but focuses on identifying if anything can be changed to prevent similar deaths in the future.

  4. Consider and analyse each child death based on information available from those who were involved in the care of the child and family, both before and immediately after the death, including information from the Coronial Service where appropriate.

  5. Have a fixed core membership to review these cases, with flexibility to co-opt other relevant professionals as and when appropriate.

  6. Meet every month to enable each child's case to be discussed in a timely manner, incorporating dedicated neonatal panels attended by Consultant Neonatologists.

  7. Review the appropriateness of the professionals' responses to each unexpected death of a child, their involvement before the death, and the relevant environmental, social, health, racial, religious and cultural aspects of each death, to ensure a thorough consideration of how such deaths might be prevented in the future.

  8. Report quarterly to the respective LSCB Boards and identify any patterns or trends in the local data. An annual report is provided to LSCB.


The Terms of Reference for the CDOP include:


Purpose

Through a comprehensive and multidisciplinary review of child deaths, the CDOP aims to better understand how and why children in Merseyside die and use findings to take action to prevent other deaths and improve the health and safety of children.

In carrying out activities to pursue this purpose, the CDOP will meet one of the functions set out in Regulation 6 of the LSCBs Regulations, in relation to the deaths of any children normally resident in their area:
  • Collecting and analysing information about each death with a view to identifying –
    • Any case giving rise to the need for a review mentioned in Regulation 5 (1) (e);
    • Any matters of concern affecting the safety and welfare of children in the area of the authority; and
    • Any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area; and
  • Putting in place procedures for ensuring that there is a co-ordinated response by the authority, their Board partners and other relevant persons to an unexpected death. (Working Together to Safeguard Children (2015), p81).

Full information regarding the CDOP process is contained within the Merseyside CDOP Protocol.


Objectives

In line with the guidance in Working Together to Safeguard Children (2015), the functions of the CDOP include:

  • Reviewing all child deaths, excluding those babies who are stillborn and planned terminations of pregnancy carried out within the law;

  • Collecting and collating information on each child and seeking relevant information from professionals and, where appropriate, family members;

  • Discussing each child’s case, and providing relevant information or any specific actions related to individual families to those professionals who are involved directly with the family so that they, in turn, can convey this information in a sensitive manner to the family;

  • Determining whether the death was deemed preventable, that is, those deaths in which modifiable factors may have contributed to the death and decide what, if any, actions could be taken to prevent future such deaths;

  • Making recommendations to the LSCB or other relevant bodies promptly so that action can be taken to prevent future such deaths where possible;

  • Identifying patterns or trends in local data and reporting these to the LSCB;

  • Where a suspicion arises that neglect or abuse may have been a factor in the child’s death, referring a case back to the LSCB Chair for consideration of whether an SCR is required;

  • Agreeing local procedures for responding to unexpected deaths of children; and

  • Cooperating with regional and national initiatives – for example, with the National Clinical Outcome Review Programme – to identify lessons on the prevention of child deaths.

In reviewing the death of each child, the CDOP should consider modifiable factors, for example, in the family environment, parenting capacity or service provision, and consider what action could be taken locally and what action could be taken at a regional or national level.

The aggregated findings from all child deaths should inform local strategic planning, including the local Joint Strategic Needs Assessment, on how to best safeguard and promote the welfare of children in the area. Each CDOP should prepare an annual report of relevant information for the LSCB. This information should in turn inform the LSCB annual report.


Definition of Preventable Child Deaths

For the purpose of producing aggregate national data, this guidance defines preventable child deaths as those in which modifiable factors may have contributed to the death. These are factors defined as those, where, if actions could be taken through national or local interventions, the risk of future child deaths could be reduced.


Scope of Cases Considered by Merseyside CDOP

Merseyside CDOP will gather and assess data on the deaths of all children and young people from birth up to the age of 18 years who are normally resident in Merseyside. This will include neonatal deaths, expected and unexpected deaths in infants and in older children. This process excludes babies who have been stillborn and planned terminations of pregnancy which have been carried out under the law (Abortion Act 1967).


Membership of Merseyside CDOP

Panel meetings are chaired by a Consultant in Public Health and attended by a representative from:

  • Public Health
  • Consultant Community Paediatricians/Consultant Neonatologists
  • Consultant Obstetrician
  • Legal Services
  • Children's Services
    • Social Care and
    • Education
  • Designated Nurse
  • Merseyside Police
  • CDOP/Specialist Nurse - AHH
  • Bereavement Services
  • Lay Members
  • LSCB Business Managers

Panel members receive a combined multi-agency report prior to the panel meeting taking place to enable them to prepare, the reports are fully anonymised and panel members return them after the meeting.

Click here to view the Merseyside Child Death Overview Panel (CDOP)


Parental Participation

A national leaflet was compiled by the Foundation for the Study of Infant Deaths (FSID) (now Lullaby Trust) in consultation with bereaved parents. This leaflet provides information relating to the child death review process in addition to the Coronial process.

A local Merseyside leaflet is available and is distributed by the Registrars at the point at which the child’s death is registered. For child deaths leading to inquest the leaflet is provided within the inquest pack. The leaflet informs parents and carers of the process that has to be undertaken and the reasons for doing so. Bereavement support resources are listed and an additional list is made available.

There is scope for parents and carers to engage with the CDOP process through written or personal contact with a panel member should they wish. It is not possible for parents or carers to participate in the meeting.


Annual Report

Merseyside CDOP compiles an annual report and quarterly reports that are distributed across the participating LSCB's. The information from quarterly reports is combined to form the annual report. All CDOP reports are fully anonymised and no individual child is identified.


Annual Data Return


CDOP is required to complete an annual return that is provided to the Department for Education (DfE). This includes data regarding the number of deaths that have been reviewed and any modifiable factors.


Merseyside CDOP Newsletter

First Edition of Merseyside CDOP Newsletter


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