Merseyside Child Death Overview Panel (CDOP)

Merseyside Child Death Overview Panel (CDOP)

Annual Report

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

LATEST:

Child Death Overview Panel Annual Report 2022/2023
Child Death Overview Panel Annual Report 2021/2022

PREVIOUS:

Historical Context

Child Death Overview Panels became a statutory function on 1.4.2008. The guidance for the functioning was set out in the Working Together to Safeguard Children 2006, revised in 2010, 2013, 2015 and 2018. Each of the five Merseyside areas 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. In April 2019 Isle of Man became part of Merseyside CDOP.

Further guidance associated with CDOPs is contained within Child Death Review Statutory and Operational Guidance (England)

The functions of CDOP are:

Have an overview of the deaths of children under the age of 18 years in Knowsley, Liverpool, St Helens, Sefton, Wirral and the Isle of Man. This includes neonatal and perinatal deaths, but not stillbirths and planned terminations of pregnancy carried out within the law. This involves a multi-agency process
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 LSCP procedures.
The Panel is not concerned with blame, but focuses on identifying whether anything can be changed to prevent similar deaths in the future.
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.
Have a fixed core membership to review these cases, with flexibility to co-opt other relevant professionals as and when appropriate.
Meet quarterly for neonatal and quarterly for non-neonatal deaths to enable each child's death to be reviewed in a timely manner.
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.
Report quarterly to the respective bodies progressing the multi-agency safeguarding arrangements, and identify any patterns or trends in the local data. An annual report is provided to LSCP.

Purpose

The over-riding purpose of reviewing all child deaths is to reduce the risk of future deaths or harm to children. CDOP is the final stage of the Child Death Review (CDR) process. On behalf of the Merseyside statutory partners, Merseyside CDOP has been established to:

provide oversight and assurance of the whole Child Death Review (CDR) processes in accordance with the National Child Death Review Statutory and Operational Guidance 2018 and Local Child Death Review policies across Merseyside.
undertake reviews of all deaths of children normally resident within any of the local authority areas where a death certificate has been issued
hold strategic partners to account in relation to any identified matters relating to the death, or deaths, that are relevant to the welfare, public health and safety of children across Merseyside.
consider what if any action should be taken in relation to any modifiable factors identified, and make recommendations to Multi-Agency Safeguarding Arrangements, Health and Wellbeing Boards and other relevant Strategic Partnerships.
Business Objectives
To identify patterns, trends and recommendations from local data and report these to the Multi-Agency Safeguarding Arrangements, Health and Wellbeing Boards and other relevant Strategic Partnerships / bodies promptly so they can take action to prevent future such deaths where possible;
To produce a CDOP annual report on behalf of the statutory partners detailing lessons learned and any relevant recommendations for actions for relevant agencies and organisations on a Merseyside basis;
To develop an annual work plan and report on progress quarterly to the strategic and statutory partners;
To have oversight of the CDR Processes including Sudden Unexpected Deaths in Children (SUDiC)protocol
To seek assurance from Strategic Partners (where appropriate) and partnerships including the Multi-Agency Safeguarding Arrangements, Health and Wellbeing Boards and other relevant Strategic Partnerships and escalate any issues if they arise. Case Discussion Objectives
to collect and collate information about each child death, seeking relevant information from professionals and, where appropriate, family members;
to analyse the information obtained, including the report from the Child Death Review Meeting (CDRM), in order to confirm or clarify the cause of death, to determine any contributory factors, and to identify learning arising from the child death review process that may prevent future child deaths;
to make recommendations to all relevant organisations where actions have been identified which may prevent future child deaths or promote the health, safety and wellbeing of children; to notify the Child Safeguarding Practice Review Panel and local Safeguarding Partners when it suspects that a child may have been abused or neglected;
to notify the Medical Examiner (once introduced) and the doctor who certified the cause of death, if it identifies any errors or deficiencies in an individual child's registered cause of death. Any correction to the child’s cause of death would only be made following an application for a formal correction;
to produce an annual report for CDR partners on local patterns and trends in child deaths, any lessons learnt and actions taken, and the effectiveness of the wider child death review process; and
to contribute to local, regional and national initiatives to improve learning from child death reviews, including, where appropriate, approved research carried out within the requirements of data protection.
to ensure that bereavement support is offered to parents

Accountability & Financial Agreement

The Merseyside CDOP is accountable to the statutory partners and the relationship with these and other strategic partners is highlighted in this Memorandum of Understanding.

The responsibility for the management of budget arrangements will be with the host organisation i.e. Liverpool City Council.

Reporting

The Merseyside CDOP will be accountable to the Statutory Partners and will report to each quarterly and annually.

Themed Panels

CDOP will determine and oversee the process for conducting thematic child death reviews, and collaboration with neighbouring areas where appropriate. Thematic reviews will also include “deep dives” into various themes on an annual basis.

Quoracy

Membership has been determined to ensure geographic (not organisational) and professional representation. The group will be quorate if the following are present:

Confidentiality

All child deaths will be discussed anonymously and papers will only be shared with panel members; it is then the responsibility of the panel member to ensure confidentiality and security of the papers. The sign-in sheet for each panel will include a confidentiality statement, and any declarations of professional interest in any of the cases.

Frequency

The Business Meetings and Neonatal panels will be held bi-monthly, and on alternate months. All other case discussions (i.e. thematic reviews) will be a full day and an annual development day will be delivered.

Destruction and Retention

All records will be kept securely until such a time when formal guidance is obtained in relation to destruction and retention of Local Safeguarding Children Partnership records.

Chair and Membership

Business Meeting	Review Meetings	Neonatal Review Meetings
Chair	Chair	Chair
Public Health	Public Health	Public Health
Children's Social Care	Children's Social Care	Children's Social Care
Merseyside Constabulary	Merseyside Constabulary	Merseyside Constabulary
Designated Doctor for Child Deaths	Paediatrician/Designated Doctor for Child Deaths	Paediatrician and/or Neonatologist /Designated Doctor for Child Deaths
Named GP for Safeguarding	Named GP for Safeguarding
Designated Nurse	Named Nurse for Safeguarding	Named Nurse for Safeguarding
SUDiC Lead Nurse	Named Midwife	Named Midwife
	Palliative care/bereavement support agencies	Palliative care/bereavement support agencies
The business lead for the multi-agency safeguarding arrangements	SUDC Nurse	SUDC Nurse
Lay/parent representative	Education (School/ Early Years Rep)	Specialist Professional: Obstetrician/ Neonatologist/
	Lay/parent representative	Lay/parent representative
	Primary Care representative	Primary Care representative
In attendance: CDOP Manager CDOP Administrator	In attendance: CDOP Manager CDOP Administrator	In attendance: CDOP Manager CDOP Administrator

Other members may be co-opted to attend the CDOP to contribute to the discussion of certain types of death when they occur. Additionally, delegates who are not members of the panel may request to observe a meeting and this will be at the discretion of the CDOP Chair. All observers will be required to sign a confidentiality agreement.

Roles and responsibilities of CDOP members

Members of CDOP are not there to represent their individual organisations, but to represent a professional perspective/ insight to the cases presented. In addition to the specific roles identified below, all members of CDOP are expected to:

Ensure that they are fully prepared to contribute at each meeting by reading through the papers, and consulting colleagues where necessary beforehand.
Ensure that there is a suitable alternative replacement to attend if it is not possible for them to do so.
Take away action points to their specific geography, agency or professional groups, and ensure that the action is undertaken within the required timescales

Independent CDOP Chair:

The Independent Chair will:

Provide oversight and assurance to the statutory partners that the local CDR processes are being discharged in accordance with the statutory guidance;

Ensure that child death reviews are effectively undertaken in accordance with statutory guidance, through multi-agency discussion of all child deaths, meetings are effectively managed and recorded, themes and trends are communicated and ensure learning from reviews is actioned.
Chair CDOP meetings effectively and ensure that all statutory requirements are met;
With the CDOP management team and the Designated Doctor, take responsibility for co-ordinating meeting dates, panel agenda, the CDOP action plan, and the production of an annual report;
Ensure that new panel members, members invited to CDOP, and observers sign a confidentiality agreement;
Coordinate with a public health professional, if attending, in order to provide the CDOP with information about epidemiological and health surveillance data; and
Assist CDOP in evaluating patterns and trends in relation to child deaths and in implementing public health prevention initiatives and programmes; Merseyside CDOP Manager and Administrator.
The CDOP Manager and Administrator will:

- Ensure the effective management of the notification, data collection and storage systems;
- Ensure the effective running of ordinary and themed panel meetings;
- Be the designated person to whom the child death notification and other data on each child death should be sent;
- Allocate a unique identifier number to a deceased child following receipt of the notification form;
- Seek to establish which agencies have been involved with the child or family either prior to or at the time of death and gain receipt of relevant information (reporting form);
- liaise with the chair of the child death review meeting to receive that meeting’s summary notes (draft analysis form); and
- Record the CDOP’s conclusions (final analysis form) and submit data to the department of health and social care and, once operational, to the national child mortality database.
- Prepare all relevant paperwork for the CDOP meeting and disseminate 5-10 working days before meeting dates to enable members to read all the material and prepare appropriately;
- Ensure and monitor the effectiveness of the data collection and ensure reports relevant to each child are combined into an anonymised single multi-agency report for review panel members;
- Provide secretarial and administrative support to facilitate the efficient implementation of the CDOP meetings,
- Ensure that new members to CDOP receive an orientation to the panel prior to their first meeting;

Support the CDOP Chair in compiling the annual report for the statutory partners and appropriate strategic partnerships including Multi-Agency Safeguarding Arrangements, Health and Wellbeing Boards, Community Safety Partnerships;
Compile a quarterly report of CDOP activity for the statutory partners
Deal with all correspondence, databases and all relevant paperwork associated with the CDOP process;
Meet/liaise with the Independent Chair prior to each CDOP for a pre-agenda meeting/discussion
Progress identified actions/preventative work in conjunction with relevant agencies as appropriate;
Receive all initial notifications of child deaths that occur in Merseyside and send requests to relevant agencies for agency checks and completion of reports;
Ensure that new panel members, ad hoc members and observers sign a confidentiality agreement;
Utilise Sentinel and pursue outstanding agency reports when the timescales for completion are exceeded and monitor Sentinel alerts
Identify and develop preventative resources

Designated/Deputy Designated Nurse

The Designated Nurse will:

Assist CDOP to evaluate health issues relating to the circumstances of the child’s death;
Advise CDOP on nursing/midwifery practices that may have had a bearing on the child’s heath or well-being;
Assist CDOP in developing appropriate preventative strategies;
Liaise with other nursing and allied health professionals as appropriate;
Liaise with other midwifery and obstetric colleagues as appropriate; and
Assist CDOP in its evaluation of perinatal deaths (antenatal and perinatal care and support for the child and mother).
Review and evaluate the practice and learning from all involved health professionals and providers commissioned across Merseyside.

Public Health

The public health representative will:

Provide the CDOP with information on epidemiological and health surveillance data;
Assist the CDOP in strategies for data collection and analysis;
Assist the CDOP in evaluating patterns and trends in relation to child deaths and in learning lessons for preventative work;
Inform the CDOP of public health initiatives to support child health improvement; and
Advise the CDOP on the development and implementation of public health prevention activities and programmes;

Designated Doctor for Child Deaths

The Designated Doctor for Child Deaths will:

Be professionally responsible for the oversight of the child death review processes and will liaise with the Independent Chair, Manager and Administrator of CDOP on CDOP agenda and themed panels;
Liaise, as appropriate, with regional clinical networks to ensure that themed panels are properly co-ordinated;
Assist CDOP in the development and implementation of appropriate preventative strategies to reduce the child deaths; and
Prepare an annual report with the Chair summarising the activities of CDOP
support and inform the annual development day
Liaise with the lead clinicians for mortality reviews in each of the Merseyside Trusts, hospices and NWAS regarding CDRMs and their outputs

Consultant Community Paediatrician/Neonatologist/Obstetrician

The Paediatrician/Neonatologist will:

Assist the CDOP in interpretation of medical information relating to the child’s death, including offering opinions on medical evidence; providing a medical explanation and interpretation of the circumstances surrounding a child’s death;
Assist with interpreting the post mortem findings and results of medical investigations;
Advise the CDOP on medical issues including child injuries and causes of child deaths, medical terminology, concepts and practices;
Provide feedback and support to medical practitioners involved in individual case management;
In preparation for the CDOP meeting read the CDOP papers which will be received approximately 5-10 days prior to the meeting;

Named GP

The Named GP will:

Provide a primary care perspective to information relating to child deaths
Liaise with GP colleagues to promote engagement in the CDOP process

Merseyside Police

The Police representative will:

Upon receipt of the CDOP Agency Report Form B, retrieve any relevant police involvement with the child and family, including any child protection concerns in respect of the deceased child and other family members, which will enable them to complete the form to provide CDOP with the information;
Submit the completed form to the CDOP Business Administrator within a requested time frame, which is generally 15 working days, using Sentinel;
Provide CDOP with information on the status of any criminal investigation;
Provide CDOP with information on the criminal histories of family members and suspects;
Identify cases that may require a further police investigation;
Provide CDOP with expertise on law enforcement practices, including investigations, interviews and evidence collection;
Help the CDOP evaluate any issues of public risk arising out of the review of individual deaths;
Liaise with other Police departments, the Coroner and the Crown Prosecution Service;
Feedback to police officers involved in individual case management;
In preparation for the CDOP meeting read the CDOP papers which will be received approximately 5-10 days prior to the meeting;

Children’s Social Care

The children’s social care representative will:

Help the CDOP to evaluate issues relating to the family and social environment and circumstances surrounding the death;
Advise the CDOP on children’s rights and welfare, and on appropriate legislation and guidance relating to children;
Identify cases that may require a further child protection investigation;
Liaise with other local authority services; and
Provide feedback to social workers and other local authority staff involved in individual case management;
In preparation for the CDOP meeting read the CDOP papers which will be received approximately 5-10 days prior to the meeting;

Education Representative

The education representative will:

Assist the CDOP in interpretation and evaluation of information about the education needs and the education service provided for the deceased child and other children within the household;
Assist the CDOP in providing appropriate preventative strategies;
Provide feedback to education staff involved with the deceased child and other family members;
In preparation for the CDOP meeting read the CDOP papers which will be received approximately 5-10 days prior to the meeting;

Lay / Parent Representative

The lay / parent representative/s will:

Participate in CDOP meetings to provide the perspective on behalf of the general public and specifically provide a voice for parents/families/carers;

Support stronger public engagement in local child safety issues and contribute to an improved understanding of CDOP work in the wider community
Challenge the statutory partners on the accessibility for the public, children and young people to its services and initiatives
Help to make links between the statutory partners and community groups in relation to improving the life chances of children
In preparation for the CDOP meeting read the CDOP papers which will be received approximately 5-10 days prior to the meeting;

Legal Representative

The legal representative will:

- Participate in CDOP meetings to provide a legal perspective when necessary within meetings

Support and challenge partner agencies with regard to interpretation of any relevant legislation

Merseyside CDOP Protocol

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). Merseyside CDOP may also review deaths of children ordinarily resident outside of Merseyside if it is deemed in their interests to do so.

Merseyside Joint Agency Protocol - Sudden Unexpected Death in Childhood (SUDiC) for children aged 0 to under 18 years

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 guide for parents and carers: The Department for Education

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, provided by Coroner's Officers. 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 bereavement support 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.

Merseyside CDOP: What we have to do when a child dies (PDF)

Annual Report

LATEST:

Child Death Overview Panel Annual Report 2022/2023
Child Death Overview Panel Annual Report 2021/2022

PREVIOUS:

Annual Data Return

CDOP is required to complete an annual return that is provided to the Department of Health (DoH). 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

Second Edition: Autumn - Safe Sleep Edition of Merseyside CDOP Newsletter

Revised Safe Sleep Edition of Merseyside CDOP Newsletter (linked to Safe Sleep Campaign)

Merseyside CDOP Plan 2019