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 2023.

There are six Merseyside CDOPs, Liverpool, St Helens, Sefton, Wirral, Knowsley and Isle of Man.

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.

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

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 December 2024

ALTE Protocol May 2024

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