Why talk about the Child Death Review Process?
Child death review is a term that is used to describe the process that is undertaken following the death of a child (less than 18 years old). Every child who is a resident in Leeds will have their death reviewed under the guidance found within Chapter 5 of Working Together to Safeguard Children 2018 (WTSC).
Information from each child death is respectfully and sensitively examined by senior professionals who consider information held by a range of services. This is to consider the needs of other children and family members in the household and to also consider any lessons to be learnt to safeguard and promote children’s welfare in the future. This process is not to apportion blame but to learn lessons that can be taken forward to improve services in the future.
How to use this briefing?
This briefing should provide you with some basic information to raise awareness within a staff team around the topic of the Child Death Review Process.
- Ask team members to read the briefing then as a group work through the information, using it as a prompt to promote discussions
- Consider if there are any further learning and development needs in your team and who is best to pursue this.
What is the Child Death Review Process in Leeds?
There are two interrelated processes that can happen under this process which may require your involvement.
- Sudden Unexpected Death in Childhood (SUDIC)
A SUDIC death is a death where it was ‘not considered as a significant possibility 24hrs prior to the death or where there was an unexpected collapse or incident leading to, or precipitating, the events that lead to the death’
The SUDIC team are informed of all SUDIC deaths at which point the team obtain as much information as possible about the circumstances of the child’s death. The SUDIC team will usually arrange to visit the place where the child died, where appropriate, within 72 hours of the death.
Following the visit, practitioners from all the agencies involved in the deceased child’s life will be invited to an Initial SUDIC Meeting. The aim of the meeting is to gather as much information as possible in relation to the child’s death and any further information relevant to the family’s needs.
The information relating to the circumstances of the death and the relevant health or social care history must be included in the SUDIC Paediatrician’s report to the HM Coroner within 28 days of the child’s death.
Once the post-mortem report is available a Final SUDIC Case Discussion meeting is held. The purpose of the meeting is to share information regarding any factors that may have contributed to the death and to enable the professionals involved to plan future care for the family.
Following the meeting, a final SUDIC report completed by the SUDIC Paediatrician, is sent to HM Coroner and the Leeds Child Death Overview Panel.
- Leeds Child Death Overview Panel (CDOP)
The CDOP meeting is the final multi-agency panel meeting for all child deaths including those that died unexpectedly or those that had a life limiting condition. The panel is made up of health specialists, childcare professionals, police and education. This panel considers all the anonymised information on each child, to try to ascertain circumstances that led to the death, what support and treatment was offered to the child and their family and what support was offered to the family after the child died. It decides whether there are any recommendations and actions needed to help prevent similar child deaths in the future.
These recommendations are directed to local health trusts, public health departments, children’s services, and the police, as well as specialist agencies such as the Ambulance Service or Road Safety Team, to influence and improve services and life chances for children and families.
Following review at CDOP information is sent to the National Child Mortality Database where a national picture is built of all child deaths in England.
The CDOP is required to produce an annual report that provides an analysis of all deaths across Leeds and any recommendations made.
Things to consider
Child deaths are emotive and can have an impact on professionals that may have worked with the child or family. It is important that services have structures of support in place for professionals both at the time of the child death and while providing information into the child death review process.
Responding to an unexpected death
If the death was unexpected and you provided services to the child or family then you may be asked to attend a SUDIC meeting and/or provide written information of your agency’s involvement. The first meeting is usually held within a week of the child death. Following receipt of the Post-Mortem Report, you may be asked to attend the Final SUDIC Meeting. This usually happens after 28 days or once all other investigations have been completed.
If the death was expected, then you will be asked to provide details of any involvement your service has had with the family. Requests will be sent by the LSCP Business Unit and a proforma will be included for your service to complete.
Areas for consideration
Although the child death review process has key agency contacts for requesting information you may be contacted directly. Please speak to you manager about this and what information has been requested.
Due to the strict timelines for SUDIC deaths to be reviewed, you may be requested to attend a professionals meeting at short notice. Please speak with your manager about this and the impact it may have on your work.
If you require any feedback from any child death review, please speak with your CDOP agency representative.