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7.1 Child Death Overview Panel Protocol

RELEVANT CHAPTERS

Rotherham Child Death Review Process Including Dealing With Unexpected Child Deaths (Rapid Response) Protocol

RELEVANT INFORMATION

MBRRACE-UK (Mothers and babies: reducing risk through audits and confidential enquiries across the UK)

SUMMARY

In the event of a child death (defined as from birth up to age 18) the ‘notifier’ will inform the Rotherham Coroner and the Chair of the Rotherham Child Death Overview Panel (RCDOP) of the death, by contacting the Panel Administrator in the Rotherham Safeguarding Children Unit.

The notifier and other key professionals will complete the relevant sections of the required data set, which will be collated by the RCDOP administrator. The Safeguarding Children Unit will analyse data and report to RCDOP at agreed times, and to RLSCB annually.

The Rotherham Child Death Overview Panel will:

  • Have a fixed core membership, with other professionals co-opted as required;
  • Hold regular meetings (at least quarterly) to discuss all child deaths as notified to them, with attention paid to specific cases, particularly of unexpected child deaths;
  • Identify, monitor and report trends in local child death data, who will decide an appropriate response in relation to lessons to be learned concerning preventable deaths and any other relevant public health messages;
  • Report to RLSCB and request ratification of recommendations as appropriate.

AMENDMENT

In December 2016, a link was added to MBRRACE-UK (Mothers and babies: reducing risk through audits and confidential enquiries across the UK) website in the Relevant Information section.


Contents

  1. Introduction
  2. Notifications to Rotherham Child Death Overview Panel
  3. Rotherham Child Death Overview Panel
  4. South Yorkshire Liaison
  5. Contact

    Appendix 1: Identifying the Notifier in the Specific Circumstances

    Appendix 2: Rotherham Child Death Overview Panel - Process Flow Chart

    Appendix 3: Abbreviations

    Appendix 4: Child death reviews: forms for reporting child deaths (GOV.UK)


1. Introduction

From 1 April 2008, it was a statutory responsibility for all Local Safeguarding Children Boards(LSCB's) to review the deaths of all those in the local authority area, from birth up to the age of 18. This is as stated in ‘Working Together to Safeguard Children’ 2010 (now archived) and repeated in Working Together 2015.

This will be achieved by the establishment of the Rotherham Child Death Overview Panel (RCDOP), which will meet regularly to monitor all child deaths, and report to the Rotherham Local Safeguarding Children Board (RLSCB) as required. For the purpose of this report, a ‘child’ is defined as all those under the age of 18.

This Protocol lays out the process that will occur from a child dying, through to reports provided to RLSCB. Other relevant protocols are the Rotherham Child Death Review Process Including Dealing With Unexpected Child Deaths (Rapid Response) Protocol and the Learning and Improvement Framework Procedure.


2. Notifications to Rotherham Child Death Overview Panel

Data Sources

Information regarding a child death will come from a variety of sources, for example Rotherham Clinical Commissioning Group; the Rotherham Registrar of Births, Deaths and Marriages; the Rotherham Coroner; Paediatricians and Accident and Emergency Departments at Rotherham District General Hospital (RDGH), Sheffield Children’s Hospital (SCH) and the Northern General Hospital (NGH); and South Yorkshire Police (SYP). Other sources may be useful such as Bluebell Wood Children’s Hospice and local funeral directors. ONS (Office of National Statistics) will provide the final data check.

The Notifier

The professional who confirms the child’s death should notify the Chair of RCDOP; they are the ‘notifier’. The designated paediatrician will also be a notifier for all unexpected deaths. This may result in some duplication but should ensure that all deaths are notified to the Chair. For unexpected deaths this will be at the same time as they inform the Coroner. They will also be responsible for completing the required data set, along with other key professionals.

Requirements from other Key Professionals

In addition to the core data required, further information should be sought from other agencies. These include summaries from Health records; Police case information; Social Care and Education; post mortem reports and other investigations; relevant information concerning the family and social circumstances; scene reports from South Yorkshire Police or accident investigators such as the Health and Safety Executive.

Data Collection and Storage

When data is received the RCDOP Administrator will input it onto a secure database (to be established).

Sharing Information

There are a number of requirements, as a result of the new child death arrangements, for agencies to share information at different levels. The notifier and all other key professionals involved with the child are required to share relevant information with RCDOP.

Collated information will be sent, at monthly intervals, to the Panel Administrator for analysis within the Safeguarding Children Unit.

A multi-agency information and data sharing agreement across Children’s Services is in place which supports work under this Protocol.

The Panel will work in accordance with the principles of ‘Organisation with a Memory’ and operate on a no fault basis unless there is clear negligence.

The Coroners (Investigations) Regulations 2013 place a duty on coroners to inform the LSCB, for the area in which the child died or the child’s body was found where the coroner decides to conduct an investigation or directs that a post mortem should take place. The coroner must provide to the LSCB 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 LSCB.

Analysis and Reporting Arrangements

The Safeguarding Children Unit will analyse received data on a monthly basis, until a time when RCDOP agrees to meet quarterly. Reports will be provided one week prior to the RCDOP meeting.

Whilst reports will include data relating to all child deaths, not all deaths will be reviewed in detail. Particular consideration should be given to the review of sudden unexpected deaths in infancy and childhood; accidental deaths; deaths related to maltreatment; suicides; and any deaths from natural causes where lessons may be learnt concerning prevention, and equalities issues.


3. Rotherham Child Death Overview Panel

Chair of RCDOP

The Chair of RLSCB will appoint the Chair RCDOP as their representative. The RCDOP Chair must be a member of RLSCB, but should not be involved in providing direct services to children and families in Rotherham.

The appointment of RCDOP Chair will be for 18 months, in the first instance and then subject to annual review by RLSCB and the employing agency after 12 months.

At the first meeting, the RCDOP will elect a vice-chair for 18 months to be reviewed after 12 months.

Membership

Membership of RCDOP will consist of standing and co-opted members.

Standing Members

The standing membership will consist of the following agencies:

  • Public Health (Chair);
  • Designated Paediatrician for Death in Childhood (RDGH);
  • Rotherham Safeguarding Unit Management;
  • South Yorkshire Police;
  • Rotherham Coroner’s Office;
  • Yorkshire Ambulance Service;
  • Rotherham Adult Services;
  • Children’s Social Care;
  • Bluebell Wood Children’s Hospice;
  • Rotherham CCG;
  • Rotherham Community Engagement;
  • Bluebell Wood Children’s Hospice.

Agencies listed above should agree who is the most appropriate member of staff to represent them on RCDOP. They should also agree a designate. When it is not possible for the agreed representative to attend, the designate should attend on their behalf. The Rotherham and Doncaster Coroner will be sent minutes of the RCDOP.

Attendance of agencies to RCDOP meetings will be monitored, as occurs with RLSCB members. If there is concern about the attendance of particular agencies, the Chair will make representation to that agency at Chief Executive level, in order to resolve the issue.

Co-opted Membership

Co-opted members will be invited when there are children to be discussed with whom they were involved or have other contributions to make. These include:

  • RDGH;
  • RDaSH Trust;
  • Designated Nurse Child Protection;
  • Strategic Health Authority;
  • RMBC Services (for example Road Safety and legal advisor);
  • Housing providers;
  • Children and Family Court Advisory and Support Service (CAFCASS);
  • National Probation Service (Rotherham);
  • Youth Offending Team (Rotherham);
  • NSPCC;
  • Domestic Abuse Forum. D V Strategic Group;
  • Rotherham Drug Action Team;
  • South Yorkshire Fire and Rescue Services;
  • Health and Safety Executive;
  • A&E Consultant;
  • And any other agency as required.

Confidentiality

Information discussed at RCDOP meetings will not usually be anonymised. Therefore members are expected to adhere to strict guidelines on confidentiality and information sharing, as per the multi-agency information sharing agreement for this purpose. Information is being shared in the public interest for the purposes as detailed in ‘Working Together to Safeguard Children’ (2015) and is bound by data protection legislation.

Members should sign the Code of Conduct. This will be referred to in the attendance register form.

Functions of RCDOP

The functions of RCDOP include:

  • Implementing this Protocol and supporting the implementation of the Rotherham Child Death Review Process Including Dealing With Unexpected Child Deaths (Rapid Response) Protocol. These are both in accordance with guidance issued in ‘Working Together to Safeguard Children’ 2015 on enquiring into unexpected deaths, and evaluating data concerning all deaths in childhood in Rotherham. This should take place in consultation with the Rotherham Coroner;
  • Collating an agreed minimum data set, and, where relevant, seeking other information from key professionals and family members;
  • Meet frequently to evaluate the above data on the deaths of all children, enabling identification of lessons to be learnt or issues of concern. This should have a particular focus on effective inter-agency working to safeguard and promote the welfare of children;
  • Consider findings presented within RCDOP related to equalities issues, specifically regarding gender, ethnicity, disability and sexuality;
  • Provide a mechanism to review specific child deaths in detail when necessary, at RCDOP meetings;
  • Monitor the appropriateness of the response of professionals to an unexpected death of a child. This will include reviewing reports received by RRRT concerning each child, recording such discussions and providing professionals with feedback about their involvement. Where there is an ongoing criminal investigation, the Crown Prosecution Service should be consulted as to what is appropriate for RCDOP to consider and what actions it can take without prejudicing any criminal proceedings. Reference must also be given to the Learning and Improvement Framework Procedure and liaison should take place between the Chair of RLSCB and the Chair of RCDOP on issues relating to abuse and neglect;
  • The Chair of RCDOP should refer to the Coroner and the Chair of RLSCB any deaths of concern, where the Panel believes that there are grounds for further enquiries or investigations and the case does not relate to abuse or neglect;
  • The Chair of RCDOP should refer to the Chair of RLSCB if RCDOP believe that there are grounds for a Serious Case Review and explore why this had not been recognised previously. Reference again should be made to the Rotherham Serious Case Review Protocol;
  • Inform the Chair of RLSCB where specific new information should be passed to the Coroner or other appropriate authorities;
  • Provide relevant information to those professionals involved with the child’s family so that they can convey the information to them in a timely and sensitive manner;
  • Provide written information for families about the role of RCDOP and the outcome of information discussed at meetings and the publication of annual RLSCB reports;
  • Monitor the support and assessment services offered to families of children who have died;
  • Monitor and advise RLSCB on the resources and training required locally to ensure an effective inter-agency response to child deaths. For example, additional questions within the data collection process to assess time taken to collate and complete the data set required for each professional;
  • Organise and monitor the collection of data for the nationally agreed minimum data set, and make recommendations for any additional information to be collected locally, both in Rotherham and in South Yorkshire as appropriate;
  • Identify any public health issues and consider, in consultation with the Director of Public Health, how best to address these and the implications for both service provision and training;
  • Co-operate with regional and national initiatives to identify lessons on the prevention of unexpected child deaths, for example the National Clinical Outcome Review;
  • Liaise with media as necessary. The annual report will be a public document, which is likely to generate interest. A planned press release may be effective in handling media enquiries, written in conjunction with RMBC press office.

Management of RCDOP Meetings

To ensure effective organisation of RCDOP meetings, the Panel Chair and the Panel Administrator will:

  • Ensure and monitor effective running of the notification, data collection and storage systems;
  • Determine meeting dates and send meeting notices to standing members;
  • Agree and notify of requirement to attend for co-opted members, as necessary;
  • Obtain names and compile summary sheet of child deaths to be reviewed and distribute to Panel members at least one week prior to meeting;
  • Ensure that notifications of child deaths are available for each Panel meeting;
  • Ensure that all Panel members sign the Code of Conduct in respect of confidentiality/information sharing;
  • Encourage the sharing of information for effective case reviews;
  • Facilitate resolution of inter-agency disputes;
  • Ensure minute taking/recording of panel meetings takes place;
  • Compile and disseminate meeting minutes;
  • Complete and submit annual report to RLSCB;
  • Monitor the outcome of recommendations and prevention initiatives and activities.

Frequency of Meetings

RCDOP will meet quarterly and after a period of six months, will review the frequency of panel meetings.

The Role of Rotherham Local Safeguarding Children Board (RLSCB)

On behalf of the RCDOP Chair, the Safeguarding Children Unit will provide annual reports to RLSCB. Regular reports will be provided at the first RLSCB meeting after 31 March each year. Additional reports will also be provided to RLSCB, if RCDOP deem necessary, for example, in the case of emerging trends that are causing concern.

It is the responsibility of RLSCB to disseminate the lessons to be learnt to all relevant organisations; ensure that relevant findings inform the Children and Young People’s Plan and act on any recommendations to improve policy, professional practice, and inter-agency working to safeguard and promote the welfare of children.

RLSCB is also responsible for supplying data on every child death to organisations commissioned by the Department of Education, so that the Department can commission bodies to undertake and publish nationally comparable, anonymised analyses of these deaths.

It will be the responsibility of the RCDOP Administrator or Safeguarding Children Unit, RLSCB, in agreement with the Chair of RCDOP, to supply data and reports to the designated RCDOP members.

It is the responsibility of RLSCB to disseminate the lessons to be learnt to all relevant organisations; RLSCB will expect partner agencies to act on recommendations to improve policy, professional practice, and inter-agency working to safeguard and promote the welfare of children.


4. South Yorkshire Liaison

In order to compare trends and any emerging patterns of causes of death in children and young people across South Yorkshire, annual meetings should take place. Membership of these meetings should consist of the Chairs of the CDOP of Barnsley, Doncaster, Rotherham and Sheffield, who should also agree any other relevant invitations.

In order to consider the effectiveness of initial arrangements and any data collection issues, it is recommended that there is a six monthly review to take place at an agreed time.


5. Contact

Child Death Overview Panel Administrator:

Telephone number: 01709 254 948

Fax: 01709 373 336


Appendix 1: Identifying the Notifier in the Specific Circumstances

Death of a Child

For the purpose of this Protocol, it is recognised that a child may die in one of a number of locations:

  • At home;
  • In hospital or in a hospice;
  • In a public location;
  • Outside of Rotherham geographical boundaries, i.e. in another local authority area, or abroad.

For RCDOP to be effective and be able to ascertain trend data and any subsequent public health messages, it is essential that all child deaths are reported. Therefore, it is important to identify all the different locations in which a child may die, as the data sources will vary accordingly.

Death of a Child at Home

When a child dies at home, it may be either an expected death due to a chronic illness, or an unexpected death due to, initially, an undetermined cause.

Unexpected Deaths

If it is an unexpected death, the Rotherham Rapid Response Team (RRRT) will be involved, as per the Rotherham Child Death Review Process Including Dealing With Unexpected Child Deaths (Rapid Response) Protocol. Under these circumstances, the designated Paediatrician will complete the data set forms. The child will be taken either to the nearest Accident and Emergency department, or will be taken straight to the Medico-Legal Centre. The Coroner will also be notified of the death. Other key professionals should also contribute to the data requirements as specified in 'Requirements from other Key Professionals'.

Expected Deaths

If it is an expected death, the General Practitioner (GP) practice will be notified of the child’s death. A GP, from the practice or other identified agency, will conduct a home visit and issue a death certificate to the family. The family should then register the death, with the Registrar at Rotherham Metropolitan Borough Council. The GP, in conjunction with other identified health professionals, should complete the data set forms, and submit it to the RCDOP Administrator for entering onto the child death database.

In summary, therefore, when a child dies at home, three sources for notification and initial completion of the data set forms have therefore been identified:

  1. The designated paediatrician from RRRT; and
  2. The GP, or locum, certifying the child’s death;
  3. Palliative care nurses.

Role of RCDOP Administrator

Regular liaison with both the Rotherham Coroner’s Office, the Rotherham Registrar and the other agencies by the RCDOP Administrator should minimise the possibility of child deaths being missed. Data from the Office for National Statistics (ONS) will also provide a check. Liaison should also occur with local funeral directors, as children who die at home following chronic illness may be taken to them because no post mortem may be required.

Identification of Possible Serious Case Review

If it is possible that a Serious Case Review is to be instigated as a result of a child dying, the Chair of RCDOP should liaise with the Chair of RLSCB and receive direction accordingly. The Serious Case Review Protocol should be adhered to. It is vital that any potential criminal investigation or potential prosecution is not impeded by the involvement of RCDOP or RRRT.

Death of a Child in a Public Location

If a child dies in a public place, as the result of a road traffic or other accident for example, the child will be taken to the nearest Accident and Emergency Department. Therefore, in such circumstances the notifier is as detailed in Section 3, Rotherham Child Death Overview Panel above.

If a child dies in a place of work, for example, as a student or employee, the Health and Safety Executive (HSE) have a responsibility to investigate the circumstances of the death. Therefore liaison should take place between the RCDOP Chair and the HSE investigator.

Death of a Child in a Local Hospital/Hospice

The identified places that a child could die in local hospitals or hospices are:

  • Rotherham District General Hospital;
  • Sheffield Children’s Hospital (0–15);
  • Northern General Hospital, Sheffield (16-17);
  • Bluebell Wood Children’s Hospice (Rotherham referrals accepted from 0-19 years of age, registration with the Health Care Commission to take young people up to the age of 28 existing on the Caseload (teenagers are living longer) Opening date to be established soon).

In RDGH, SCH and NGH, a child may die in Accident and Emergency, or after being admitted to a ward or unit. On these occasions it is the Doctor responsible for the care of the child who is designated as the notifier, who must inform the Coroner and RCDOP of the death.

In the case of Bluebell Hospice, Rotherham CCG will be informed by the Hospice and will then contact RCDOP Chair.

Death of a Child usually Resident in Rotherham in another Local Authority Area or Abroad

There will be occasions when a child will die outside of the Rotherham area. However, all efforts must be made to include details of the child and the circumstances of their death for the RCDOP analysis.

It is recommended that when a child dies in another local authority area, it is the responsibility of the Chair of the area CDOP to inform the Chair of RCDOP about the death. Agreement must be reached between the two Chairs as to which CDOP will review the death. This would normally be the CDOP for the area of residence, although some details will be required for the data set forms from the host CDOP. It should also be agreed as to how the host CDOP will be informed of the outcome of the review.

There are no such arrangements for receiving notification of the death of a child abroad. Any professional hearing of such an event should notify the Chair of RCDOP. The RCDOP Administrator and the Safeguarding Children Unit, RLSCB along with other colleagues should regular review local media reports for details of any such deaths. On receipt of information concerning the death of a child abroad, the Chair of RCDOP will instigate subsequent enquiries, including family liaison. They will also designate who should be the notifier to complete the data set forms as required.

Death of a Child in Rotherham who is Resident in another Local Authority Area

In cases where organisations in more than one LSCB area have known about or have had contact with the child, lead responsibility should sit with the LSCB for the area in which the child was normally resident at the time of death. Other LSCBs or local organisations which have had involvement in the case should cooperate in jointly planning and undertaking the child death review. In the case of a looked after child, the LSCB for the area of the local authority looking after the child should exercise lead responsibility for conducting the child death review, involving other LSCBs with an interest or whose lead agencies have had involvement as appropriate.


Appendix 2: Rotherham Child Death Overview Panel - Process Flow Chart

Click here to view Appendix 2: Rotherham Child Death Overview Panel - Process Flow Chart.


Appendix 3: Abbreviations

Abbreviations
CEMACH Confidential Enquiry into Maternal and Child Health
CDOP Child Death Overview Panel
RCDOP Rotherham Child Death Overview Panel
RDGH Rotherham District General Hospital
NGH Northern General Hospital
SCH Sheffield Children’s Hospital
RRRT Rotherham Rapid Response Team
RLSCB Rotherham Local Safeguarding Children Board
RRRT Rotherham Rapid Response Team


Appendix 4: Child death reviews: forms for reporting child deaths (GOV.UK)

Click here to view Appendix 4: Child death reviews: forms for reporting child deaths (GOV.UK).

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