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OxfordshireSafeguarding Children Board Procedures Manual

Child Death Reviews


This is a simple guide to the initial process in the event of a child death and the role of the Child death overview panel. Each agency has its own policies and procedures to follow in the event of a child death. Please refer to these within your own agency.


A link to 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) was added into the Further Information section in November 2017.


  1. The Child Death Review Process
  2. What to do in the Event of a Child's Death
  3. Who is Responsible for Undertaking Child Death Reviews in Oxfordshire?
  4. How Can I Find Out More about Child Death Review Processes
  5. Further Information

1 The Child Death Review Process

From April 2008 Local Safeguarding Boards have had a mandatory function to manage a child death review process. Deaths of all children, up to the age of 18 years (excluding babies who are stillborn and planned terminations carried out within the law) whose home address is in Oxfordshire need to be reviewed, taking into account all available information for each death. The principles underlying the review of all child deaths are:

  • Every child's death is a tragedy for the family and for the wider community;
  • By reviewing child deaths we can learn lessons to prevent future child deaths;
  • Joint agency working draws on the skills and particular responses of each professional group;
  • Child Death Reviews should lead to positive action to safeguard and promote the welfare of children.

The overarching goal of this process is to reduce the number of child deaths. The review aims to ensure that there is a full understanding of the events leading to the child's death. Any recommendations arising from a review should lead to improved services for children and their families, both at local and national level.

The Child Death Overview Panel (CDOP) is also required to receive notifications about the deaths of children not normally resident in the Oxfordshire area but who die in Oxfordshire. The OSCB will notify the LSCB CDOP Panel in the area linked with the child's home address that will then be responsible for coordinating the information gathering and complete the review process.

2. What to do in the Event of a Child's Death

Each service provider has its own process and policies which must be followed in the immediate event of a child death.

All deaths of children in Oxfordshire or whose home address is Oxfordshire must also be reported to the Child Death overview panel this is for notification purposes and should be on a Form A2.

Once completed the form should be e mailed to the secure e-mail address OCCG.cdopoxfordshire@nhs.net (please note this is only secure if you are sending information from a secure e-mail address) the form should be completed as soon as possible after the child's death. Calls for advice and further information/guidance and initial notification if required can be made to 01865 337023. This number is manned in office hours and a message can be left out of hours.

Initial bereavement support is facilitated by professionals involved with the family at the time of the death. This can be supported by the Oxfordshire University Hospital Rapid response Team. The Rapid Response Team works with agencies to collect the immediate information about an unexpected child death whilst giving pastoral support to the bereaved family and wider community. They can be contacted through the main Oxford University Hospitals NHS Foundation Trust switchboard (01865 741166) and request them to page the Rapid Response Team.

The Designated doctor for Child deaths will be notified to review and advise on the appropriate support and review pathway for each child death situation.

All deaths of children under 18 years old in Oxfordshire should be reported to the police.

  • The involvement of the police is routine and does not assume suspicion;
  • Where the death is unexplained and there are concerns about abuse or neglect, the police will be the lead agency. It will be the responsibility of all relevant partner agencies to support the police investigation. It is therefore, vital that staff maintain accurate records of their involvement with the family so that all relevant information can be obtained effectively and in a timely manner;
  • The family may well be in need of support services and any other children within the family may be in need of protection. Inter-agency collaboration is therefore essential. Staff need to be aware that on occasions, the early arrest of the parent/s-carer/s may be essential in order to secure and preserve evidence as part of an investigation;
  • Staff should always identify and enquire about the siblings and ensure they are being cared for appropriately, taking account of possible risks to other children in the household.

Police investigation

The police will begin an investigation into the unexpected death of a child on behalf of the coroner. 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.

The following documents may assist the police in carrying out their investigations:

MASH Should be notified on 0845 050 7666 by the person making the CDOP notification. MASH will undertake a check of the Children's Social Care (CSC) database and other agencies involved and notify the CDOP office on OCCG.cdopoxfordshire@nhs.net or 01865 337023 of the agencies involved and provide contact details for the allocated professionals.

The Safeguarding Manager for Childrens Social care should also be notified on shaun.hanks@oxfordshire.gov.uk. The Safeguarding Manager will:

  • Review the CSC involvement and agree who will attend any Rapid Response meeting;
  • Agree who will complete the Form B and by what date (within the three week statutory requirement);
  • Consider if this constitutes a 'notifiable incident' to Ofsted;
  • Consider if this incident needs to be escalated

3. Who is Responsible for Undertaking Child Death Reviews in Oxfordshire?

OSCB (Oxfordshire Safeguarding Children Board) is charged under the Children Act 2004 to establish a Child Death Overview process, which includes a Rapid Response function and the CDOP (Child Death Overview Panel).

The Rapid Response process (RRP) is a comprehensive and multi-agency review of all unexpected child deaths. Professionals involved in this process provide initial support to the family and help to inform the subsequent CDOP review process.

An unexpected death is defined (in chapter 5, of Working Together to Safeguard Children) as the death of an infant or child (less than 18 years old) which:

  • Was not anticipated as a significant possibility i.e. 24 hours before the death;

  • Where there was a similarly unexpected collapse or incident leading to or precipitating the events which led to the death.

The CDOP panel is a sub group of the OSCB that reviews all deaths of children under 18 years occurring in Oxfordshire and reviewing all children whose home address is Oxfordshire to:

  • Classify cause of death;
  • Identify modifiable factors;
  • Decide on preventability of death;
  • Consider whether to make recommendations and to whom they should be addressed.

    (DfE classifications in Form C)

The panel includes lay members and professionals delegated to the panel from all board members. For specialist advice, additional professionals may be co-opted to join the Panel. The CDOP meets bi-monthly. On concluding each review, the Panel makes recommendations which can include matters affecting the safety and welfare of children in Oxfordshire and wider public health concerns. These are referred back the OSCB and national offices as appropriate for further action.

4. How can I find out more about Child Death Review Processes?

Chapter 5 in Working Together to Safeguard Children gives a detailed overview of Child Death Review Processes.

This overview includes flow charts for the processes to follow in the case of a child death.

The Department for education (DfE) have produced an information booklet for bereaved families, explaining the Child Deaths Review process.