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9.2 Child Death Overview Panel


This chapter is a guide to the Child Death Overview Panel and the related processes. Under Regulation, the LSCP is required to provide an overview, together with the collection and analysis of information, of all deaths, including sudden and unexplained deaths, of children under 18 years and identify whether there are broader issues of children's safety within the community, or whether a serious case review should be undertaken with respect to a child's death. The aggregated findings from all child deaths should inform local strategic planning, including the local Joint Strategic Needs Assessment, on how to best safeguard and promote the welfare of children in the area.


Sudden Unexpected Deaths in Childhood Protocol


Merseyside Child Death Overview Panel (CDOP) Protocol

Child Death Overview Panel: Information Leaflet for Parents

Child Death Review: A Guide for Parents and Carers - DfE

The Royal College of Pathologists and Royal College of Paediatrics and Child Health, Sudden Unexpected Death in Infancy and Childhood - Multi-agency Guidelines for Care and Investigation (2016)


This chapter was updated in March 2018 by adding a link to The Royal College of Pathologists and Royal College of Paediatrics and Child health, Sudden Unexpected Death in Infancy and Childhood - Multi-agency Guidelines for Care and Investigation (see Relevant Links above).


  1. Introduction: Regulation
  2. Overall Principles
  3. Process
  4. Definition of an Unexpected Death
  5. Coroner
  6. Involving Parents, Families and Carers

    Appendix A: Merseyside Child Death Notification Form

1. Introduction: Regulation

Regulation 6 of the Local Safeguarding Children Partnership Regulations 2006 places a statutory duty on LSCPs in relation to the deaths of any children normally resident I in their area. Guidance regarding the process is provided in Chapter 5 of Working Together to Safeguard Children. This function became a statutory requirement from 1st April 2008. This chapter will set out the principles relating to when a child dies in Liverpool Safeguarding Children Partnership area.

The guidance in this chapter relates to the deaths of all children and young people from birth (excluding those babies who are stillborn or planned terminations that are within the law but including children with life limiting conditions) up to the age of 18 years.

From April 2008 each of the Merseyside LSCPs, Knowsley, Liverpool, Sefton, St Helens, and Wirral operated CDOPs independent of each other. In April 2011 four of the Merseyside LSCPs merged, Knowsley remained independent until April 2014 but is now part of Merseyside CDOP, hence these procedures apply to all LSCP areas in Merseyside

There are two interrelated processes for reviewing child deaths:

  1. A rapid response by a group of key professionals who come together for the purpose of enquiring into and evaluating each unexpected death of a child;
  2. An overview of child deaths in Liverpool LSCP area undertaken by the Merseyside Child Death Overview Panel.

Regulation 6 (LSCP Regulations 2006) requires the collection and analysis of information about each child death known to agencies in their area with a view to identifying:

  1. Any case giving rise to the need for a Serious Case Review;
  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 that area.

    Putting in place procedures for ensuring that there is a coordinated response by the authority, their LSCP partners and other relevant persons to an unexpected death.

2. Overall Principles

The death of a child is traumatic for family members, hence subsequent enquiries/investigations should keep an appropriate balance between forensic and medical requirements and the family's need for support. Children with a known disability or a medical condition should be responded to in the same manner as any other children. A minority of unexpected deaths are the consequence of abuse or neglect, or are found to have abuse or neglect as an associated factor. In all cases enquiries should seek to understand the reasons for the child's death, address the possible needs of other children in the household, the needs of all family members and also consider any lessons to be learnt about how best to safeguard and promote children's welfare in the future. This should be done without compromising any potential investigation if one is being pursued.

At the same time, families should be treated with sensitivity, discretion and respect and professionals should approach their enquiries with an open mind.

For all child deaths from 0-18 years, irrespective of age, a review by CDOP is progressed.

3. Process

Following a child death paediatric liaison staff in hospitals, or identified staff in other health resources, complete an initial notification (see Appendix A) informing the Merseyside CDOP Manager and Administrator that a child death has occurred.

On receipt of an initial notification requests are sent to agencies to check their records. If the child or family members are known or have been known in the past agencies are required to complete an agency report with the information they hold and return to the CDOP team. All agency reports are merged into a single multi-agency report that is anonymised for panel members to receive. Multi-agency reports are disseminated in advance of the CDOP meeting to enable panel members to prepare for the meeting, and returned after the meeting to be destroyed. Merseyside CDOP holds copies of reports in relation to child deaths in a secure environment.

Each child's death is considered in relation to the circumstances of the death, any factors pertinent to the child, family, or services provided and the analysis concludes with the categorisation of death and whether any modifiable factors are identified. If there are modifiable factors evident recommendations can be made to aim to prevent a death of a similar nature in the future. CDOP may identify issues that cannot be linked to the death but are nevertheless concerning and these, along with learning points and recommendations for change are referred to the respective agency and LSCP. Further information relating to the CDOP process can be found in the Merseyside Child Death Overview Panel (CDOP) Protocol.

In circumstances where the death is unexpected and unexplained it will be necessary to pursue enquiries/investigations involving LSCP partner agencies: Police, Health and Social Care as a minimum, but others as appropriate. In these circumstances agencies are required to follow the Sudden Unexpected Death in Childhood (SUDiC) Protocol (0-18 years) (see Sudden Unexpected Deaths in Childhood Protocol). It is important that an appropriate balance is achieved between forensic and medical requirements for investigation and the family's need for support.

4. Definition of an Unexpected Death

An unexpected death is defined as, 'the death of a child that was not anticipated as a significant possibility, for example 24 hours before the death; or where there was a similarly unexpected collapse or incident leading to or precipitating the events that led to the death'.

The Designated Paediatrician should be consulted where professionals are uncertain about whether the death is unexpected. If in doubt these procedures should be followed until the available evidence enables a different decision to be made, and always with the consent of the Coroner.

When a child dies unexpectedly, several investigative processes may be instigated, particularly when abuse or neglect is a factor. In following the SUDiC protocol (see Sudden Unexpected Deaths in Childhood Protocol) the guidance will ensure that the relevant professionals and organisations work together in a co-coordinated way, in order to minimise duplication and ensure that the lessons learnt contribute to safeguarding and protecting the welfare of children in the future. Where there is an ongoing criminal investigation, the Crown Prosecution Service must be consulted as to what is appropriate for the professionals to be doing, and what actions to take in order not to prejudice any criminal proceedings.

5. Coroner

The Coroner is notified of all sudden unexpected deaths immediately after they occur and there is regular consultation with the Coroner for the duration of any investigation and subsequent proceedings as per the SUDiC protocol. Not all child deaths are notified to the Coroner, it is not necessary if the cause of the child's death is known and there are no concerning circumstances.

However, under the Coroners (Investigations) Regulations 2013, where the coroner decides to conduct an investigation or directs that a post mortem should take place, the Coroner must provide to the LSCP all information held by the Coroner relating to the child's death.

Where the Coroner makes a report to prevent other deaths, a copy must be sent to the LSCP.

6. Involving Parents, Families and Carers

Merseyside CDOP has produced a leaflet entitled 'What we have to do when a child dies' that is distributed by Merseyside Registrars on behalf of CDOP. This occurs when the child's death is registered. If an inquest is being held the leaflet is given as part of the Inquest pack as registration of the cause of death will not occur until the Inquest has concluded.

Parents, families and carers can participate in the CDOP process through conveying written or verbal information to the CDOP Manager or a panel member. They cannot attend the meeting, but can meet the CDOP Manager or a panel member should they wish.

The Department for Education produced a leaflet entitled 'The Child Death Review' that describes a number of processes associated with a child's death, including the Inquest and post mortem, in addition to the review by a Child Death Overview Panel.

Appendix A: Merseyside Child Death Notification Form

Click here to view Appendix A: Merseyside Child Death Notification Form.