Child Death Review

Child death review arrangements were managed locally in Barking and Dagenham until September 2019. In line with revised statutory guidance, these arrangements have been re-located to the North East London Health Partnership, as part of a tri-borough arrangement for Barking and Dagenham, Havering and Redbridge (BHR). 

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 local arrangements for implementing the Child Death Review (CDR) system have been agreed across Barking and Dagenham, Havering and Redbridge and can be found here:

Barking and Dagenham, Havering and Redbridge Child Death Review (PDF, 1.52 MB)

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 (2018) 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.

Statutory guidance for all multi-agency professionals (PDF, 1.3 MB)

Notification of a Child Death

The notification of a child death should be undertaken via completion of Form A on the eCDOP System within 24 hours using the link below:

BHR eCDOP System

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)

BHR Child Death Overview Panel (CDOP) is now part of this tri-borough arrangement.  The aims of the panel are to: Learn from the deaths of children to help identify ways of preventing future deaths. Identify any improvements that can be made in the services provided to children and their families. Improve the experience of bereaved families and support professionals to care for families effectively. It is a multi-agency panel, set up by the CDOP Manager for BHR (NHS) and attended by the CDR Partners who are senior professionals who would not have provided care for the child during their lifetime which ensures independent scrutiny.

Joint Agency Reviews (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.