When a child up to the age of 18 dies, there are certain processes that have to be followed to help us understand the reasons for the child's death, and enable us to address the possible needs of other children and family members in the household. Developing a better understanding of child deaths, and considering lessons we can learn from each case, helps us develop more effective prevention strategies for safeguarding children's welfare in the future.
The information below sets out the arrangements for a child death review across South Yorkshire which includes Barnsley, Doncaster, Rotherham and Sheffield.
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This document sets out how the Child Death Review partners and professionals in agencies across the four Local Authority areas in South Yorkshire will work together to review child deaths at a local level, and across the county of South Yorkshire, in order to identify learning that may help to prevent future child deaths. Across South Yorkshire there are approximately 100 child deaths per year and this will provide a larger cohort of data to enable better identification of themes, trends and learning.
The death of a child is a devastating loss that profoundly affects bereaved parents as well as siblings, grandparents, extended family, friends and professionals who were involved in caring for the child in any capacity. Families experiencing such a tragedy should be met with empathy and compassion. They need clear and sensitive communication. They also need to understand what happened to their child and know that people will learn from what happened.
The process of expertly reviewing all children’s deaths is grounded in deep respect for the rights of children and their families, with the intention of preventing future child deaths.
The Child Death Review process covers children; a child is defined as a person under 18 years of age. A child death review must be carried out for all children regardless of the cause of death.
This includes the death of any live-born baby where a death certificate has been issued. In the event that the birth is not attended by a healthcare professional, child death review partners may carry out initial enquiries to determine whether or not the baby was born alive. If these enquiries determine that the baby was born alive the death must be reviewed.
For the avoidance of doubt, it does not include stillbirths, late foetal loss, or terminations of pregnancy (of any gestation) carried out within the law.
Cases where there is a live birth after a planned termination of pregnancy carried out within the law are not subject to a child death review.
The process of expertly reviewing all children’s deaths is grounded in deep respect for the rights of children and their families, with the intention of preventing future child deaths.
The Child Death Overview Process within South Yorkshire will:
The Child Death Review partners are local authorities and clinical commissioning groups for the local area as set out in the Children Act 2004 (the Act), as amended by the Children and Social Work Act 2017.
Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children (July 2018)
and
Child Death Review Statutory and Operational Guidance (England) (October 2018). These documents provide the statutory guidance for reviewing child deaths in England.
In addition, Working Together: transitional guidance also published in July 2018 provides for the transition to Child Death Review Partners in 2019.
For the purposes of these arrangements, the responsible Child Death Review partners and the accountable officers in South Yorkshire are made up of the local authorities and clinical commissioning groups in Barnsley, Doncaster, Rotherham and Sheffield.
Child Death Review partners within South Yorkshire will make 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.Child Death Review partners within South Yorkshire will 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 the Death Review partners within South Yorkshire find action should be taken by a person or organisation, they will inform them. In addition, the Child Death Review partners will, at such times as they consider appropriate, prepare and publish reports on:
The child death review partners for the local authority area in South Yorkshire where a child who has died was normally resident will be responsible for ensuring the death is reviewed. However, they may, in some circumstances, also choose to review the death of a child in their local area even if that child is not normally resident there. Child death review partners may wish to consider this for the deaths of looked-after children in their area who were not normally resident there. The review process will seek to involve child death review partners for another local authority area who had an interest in the child or any other person or agencies, as appropriate.
Each of the four local areas within South Yorkshire will retain local processes, Child Death Overview Panel (CDOP) and supporting pathways to review deaths of children who have died in and were normally resident in their area; and if they consider it appropriate the deaths of non-resident children who have died in their area.
Each local CDOP will be accountable to the local Child Death Review Partners in that area and arrangements for accountability and reporting will be decided at a local level.
The key function and responsibilities of each of the four local area CDOPs in South Yorkshire are to:
Core representation of each of the local Child Death Overview Panel will ideally include: public health; the designated doctor for child deaths for the local area; children’s social care services; police; the designated doctor or nurse for safeguarding; primary care (GP or health visitor); nursing and/or midwifery; lay representation; and other professionals that child death review partners consider should be involved. However, it is for child death review partners at a local level to determine what representation they have in any structure reviewing child deaths.
Each local area will develop its CDOP Terms of Reference and local pathways to enable it to fulfil statutory guidance with regard to reviewing child deaths; and publish these within local safeguarding children procedures. The local pathways to support the child death review process should also cover the following:
Deaths in specific situations:
The South Yorkshire Child Death Overview Panel will not review individual child deaths. Its purpose is to regularly review and analyse data and information about all child deaths (across the South Yorkshire footprint of approximately 100 to 120 child deaths per year) that have already had a local review undertaken. This will enable further analysis, identification of trends and learning to be gained, in order to prevent future child deaths. Each of the four areas in South Yorkshire have implemented the eCDOP system to enable more effective information sharing, data analysis across the county; and direct data link to the National Child Mortality Database.
Such arrangements will facilitate appropriate professional experts being present to inform discussions, and allow easier identification of themes when the number of deaths from a particular cause is small. By necessity themed panels will need to have access to more detailed but anonymised case information. In order to ensure the effectiveness of these discussions the level of information sharing should be proportionate but allow for meaningful analysis to take place.
In order to do this the South Yorkshire CDOP will:
The arrangements for the conduct of the meetings will include the following:
The South Yorkshire CDOP is a multi-professional panel whose core membership may include senior representatives from the following agencies or roles:
Additional professionals should be considered in relation to specific themes or specialist role, for example; coroner’s office, ambulance service or hospices.
In order for the meeting to be quorate, there must be at least one representative from each local authority, with a maximum of 4.
Administration for the South Yorkshire CDOP will be provided from the same area as the incumbent chair though this will require the support and collaboration from the other local CDOP administrators.
The terms of reference for South Yorkshire CDOP will be ratified by the respective Child Death Review Partners (CCG and Local Authority).
The Terms of reference will be reviewed annually.
A memorandum of understanding will be implemented between the Child Death Review Partners, which sets out how they will work together.
A South Yorkshire CDOP annual report will be developed and published annually outlining the effectiveness of the South Yorkshire arrangements, including what lessons have been learned and actions taken to prevent future child deaths across the county. This report will be submitted to the local Child Death Review Partners.
The South Yorkshire Child Death Review Arrangements will adhere to the Data Protection Act 2018 and the General Data Protection Regulations.
The eCDOP system which feeds local data directly into the National Child Mortality Database has undergone a Data Protection Impact Assessment.
The South Yorkshire Child Death Review Arrangements is a statutory partnership function, and is not a public authority for the purposes of the Freedom of Information Act 2000.
The Child Death Review Arrangements at each local area level in South Yorkshire will adhere to the Working Together Transitional Guidance (July 2018) for the purposes of uncompleted child death reviews at the point of implementation of the new arrangements.