Merseyside Child Death Overview Panel (CDOP)
Merseyside Child Death Overview Panel (CDOP)
Annual Report
Merseyside CDOP compiles an annual report which is distributed across the participating LSCPs and to the Health and Wellbeing Boards in all areas. When CDOP reviews any death, all the reports are fully anonymised to ensure that no individual child is identified.
Latest:
Previous Annual Reports:
Historical Context
Child Death Overview Panels became a statutory function on 1st April 2008. The guidance for functioning was set out in Working Together to Safeguard Children and this remains the case. The responsibilities placed on CDOP is outlined in Chapter Six of the 2023 revision.
There are six areas covered by the Merseyside and Isle of Man CDOP – Isle of Man, Knowsley, Liverpool, Sefton, St Helens and Wirral.
Further guidance associated with CDOPs is contained within Child Death Review Statutory and Operational Guidance (England)
The functions of CDOP are:
- To have an overview of the deaths of all 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 or planned terminations of pregnancy carried out within the law. Merseyside and Isle of Man CDOP may also review deaths of children ordinarily resident outside of Merseyside if it is deemed in their interests to do so.
- Through early liaison between members of CDOP and the LSCP, to identify deaths in which there may be multi-agency learning. These can then be reviewed in line with LSCP procedures.
- Not to be concerned with blame, but focus on identifying whether anything could be changed to prevent similar deaths in the future, to improve outcomes for children, or the service offer for bereaved families.
- To consider and analyse each child death based on information available from those who were directly involved in the care of the child and family, both before and immediately after the death, including information from the Coronial Service where appropriate.
- To have a fixed core membership to review these cases, with flexibility to co-opt other relevant professionals as and when appropriate. This helps with consistency in decision-making and familiarity with processes.
- To meet quarterly for neonatal and quarterly for non-neonatal deaths to enable each child's death to be reviewed in a timely manner.
- To review the appropriateness of agency and professionals' responses to each unexpected death of a child. Considering 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 where possible.
- To identify any patterns or trends in the local data and respond to these appropriately – sharing relevant information and working with agencies where there are emerging concerns to address them quickly and robustly ensuring that all necessary safeguarding steps are taken.
- To ensure all child deaths and the outcomes of the Panel reviews are reported to the National Child Mortality Database (NCMD) in a timely way.
Purpose
The over-riding purpose of reviewing all child deaths is to analyse the circumstances relating to the death and consider if any actions need to be taken. The Panel review meeting is the final stage of the Child Death Review (CDR) process. On behalf of the Merseyside and Isle of Man statutory partners, our 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 harm where possible;
- To produce a CDOP annual report on behalf of the statutory partners detailing modifiable factors identified at Panel and any recommendations or actions for relevant agencies and organisations;
- To develop an annual work plan and report on progress quarterly to the strategic and statutory partners at the Business Review Group;
- 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 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 promote the health, safety and wellbeing of children or prevent future child death; to notify the Child Safeguarding Practice Review Panel and local Safeguarding Partners when it suspects that a child may have been abused or neglected;
- where necessary, to notify the Medical Examiner 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, including any lessons learnt and subsequent actions taken
- 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 and families.
Accountability & Financial Agreement
Merseyside and Isle of Man CDOP is accountable to the statutory partners and the relationship with these and other strategic partners is highlighted in CDOP’s 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 at the Business Review Group and annually via the Annual Report.
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.
Quoracy
Membership has been determined to ensure geographic (not organisational) and professional representation.
Confidentiality
All child deaths are discussed anonymously, and papers will only be shared with Panel members. It is the responsibility of the Panel member to ensure confidentiality and security of the papers. The sign-in sheet for each panel includes a confidentiality statement, and any declarations of professional interest in any of the cases.
Frequency
The Business Review Group meetings will take place quarterly. Neonatal and Non-neonatal Panels will also be held quarterly. All other case discussions (i.e. thematic reviews) will take place on an ad-hoc basis.
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 Child Death Review records.
Roles and responsibilities of CDOP members
Members of CDOP are not there to represent their individual organisations, but to represent a professional perspective / provide insight to the cases presented. 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
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.
Links to relevant Protocols
Merseyside Joint Agency Protocol - Sudden Unexpected Death in Childhood (SUDiC) for children aged 0 to under 18 years December 2024
ALTE Protocol May 2024 (This is currently out for final comments and then will be circulated early Sept so this will need updating then)
Parental Participation
A national leaflet was compiled by the 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, 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.
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 identified.