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WokinghamSafeguarding Children Board Procedures Manual

Child Death Overview Panels (CDOP)


The Department for Education has released the updated version of Working Together to Safeguard Children. Following the release of the revised guidance, local authority areas have until the 29th June 2019 to make the transition from LSCBs to safeguarding partner and child death review partner arrangements.

They must have published their arrangements by 29th June 2019, but may do so at any time before the end of that period. Following publication of their arrangements, the safeguarding partners have up to 3 months from the date of publication to implement the arrangements. All new local arrangements must have been implemented by 29th September 2019. 

The Safeguarding Partners working with LSCB will keep you informed of any changes and the procedure will be updated to reflect these new arrangements.


In January 2018 in further information a link was added to Sudden Unexpected Death in Infancy and Childhood - Multi-agency Guidelines for Care and Investigation.

Working Together to Safeguard Children defines an unexpected death "as the death of an infant or child which was not anticipated as a significant possibility for example, 24 hours before the death; or where there was an unexpected collapse or incident leading to or precipitating the events which lead to the death."

The designated paediatrician responsible for unexpected deaths in childhood should be consulted where professionals are uncertain about whether the death is unexpected. If in doubt, the processes for unexpected child deaths should be followed until the available evidence enables a different decision to be made.

The Local Safeguarding Children Boards Regulations 2006 require LSCBs to put in place the following functions:

  1. Collecting and analysing information about each death with a view to identifying:
    1. Any case giving rise to the need for a review mentioned in regulation 5(1)(e);
    2. Any matters of concern affecting the safety and welfare of children in the area of the authority;
    3. Any wider public health or safety concerns arising from a particular death or from a pattern of deaths in the area.
  2. 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.

Each death of a child is a tragedy and enquiries should keep a balance between the forensic and medical requirements and supporting the family at a difficult time. The purpose of the child death review is to help prevent such child deaths in the future and professionals supporting the parents and family members should assure them that the objective of the child death review process is not to allocate blame, but to learn lessons.

In order to do this the LSCB is required to have a Child Death Overview Panel (CDOP) which is responsible for reviewing the available information on all child deaths. The membership of the panel must be drawn from the key agencies represented on the Board, but it may co-opt other relevant practitioners as and when required. In Berkshire the six LSCB's have one single CDOP which fulfils the requirements of the guidance. Information regarding the Pan Berkshire CDOP can be found on each of the LSCB websites.

In reviewing the death of each child, the CDOP:

  • Will review all child deaths, excluding those babies who are stillborn and planned terminations of pregnancy carried out within the law;
  • Collect relevant information on each child from professionals and, where appropriate, family members;
  • Discuss each child's case and provide information to professionals who are directly involved with the family so that this information can be conveyed sensitively to the family;
  • Determine 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 such deaths for the future;
  • Consider any 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;
  • Identify when a suspicion arises that neglect or abuse may have been a factor in the child's death, the CDOP panel will notify the LSCB to decide whether a Serious Case Review is required.

The Berkshire CDOP website provides information on the key functions and actions.

The local Protocol includes arrangements and contacts for notifications to the relevant agencies. Any person notifying the designated person in the LSCB of the death of a child should provide as much detail as is known to them in relation to the child and family and the circumstances of the death. They should inform the designated person of any professionals known to be involved with the child or family.

Further Information

Sudden Unexpected Death in Infancy and Childhood - Multi-agency Guidelines for Care and Investigation (Royal College of Pathologists, endorsed by The Royal College of Paediatrics and Child Health) - These guidelines have been produced with input from all professional groups involved in the investigation of sudden unexpected death in infancy and childhood, and are based on the best current international research.

Local Information

To follow.