Skip to main content
Access keys Home News Site map Site help Complaints Terms Contact us

12 Child Death Overview Panel

The LSCB functions in relation to child deaths are set out in Regulation 6 of the Local Safeguarding Children Boards Regulations 2006, made under section 14(2) of the Children Act 2004. The LSCB is responsible for:

  1. collecting and analysing information about each death with a view to identifying:
    • any case giving rise to the need for a review;
    • any matters of concern affecting the safety and welfare of children in the area of the authority;
    • any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area; and
  2. putting in place procedures for ensuring that there is a coordinated response by the authority, their Board partners and other relevant persons to an unexpected death

South Gloucestershire joins with the other local authorities of the ex-Avon area (Bath & North East Somerset, Bristol and North Somerset) to make up the West of England CDOP.

The West of England CDOP has undertaken a consistently detailed overview of child deaths which have occurred in the area.  The panel has benefited from being able to draw upon valuable local and national expertise to inform consideration of cases. It has also been proactive in pursuing modifiable factors which have potential for improving policy, practice and learning for the future.

CDOPs annual reports are presented to the four LSCBs in the autumn, therefore, reporting in the Board annual report is always for the previous year.

During the period 2010-2014, 483 child deaths were notified to The West of England CDOP. During 2013–14, 111 child deaths were notified of which 12 were resident in South Gloucestershire.

Notifications by category of death, 2010-2014

Notifications by category of death, 2010-2014

Themes emerging from aggregate review of cases at CDOP during the year April 2013 – March 2014

Safe-sleeping advice

CDOP has reviewed safer sleeping leaflets and verbal information given to new parents and concluded that these messages are accurately represented. However parents do not always adhere to this advice. Research is ongoing into the factors influencing decisions about sleeping arrangements. Rather than changing local parent education strategies WOE CDOP has contributed this data to the current NICE review of co-sleeping which will make national recommendations.

Continuing training for professionals involved in the child death review process

This year has seen the development of some additional guidance for rapid response professionals and other agencies with responsibility for chairing local child death review (CDR) meetings. This was identified as a local need due to the wide range of professionals who adopt the chairing role in this region and was designed to help to bring more consistency in the way in which these meetings are arranged and carried out. The new guidance is now available to any professionals involved in the CDR process and has been useful in ensuring the correct professionals are present to ensure a robust child death review discussion.

In addition the Designated Doctor for Children’s Deaths in the West of England has met with several specialist groups including paediatric cardiologists, paediatric emergency department consultants, community paediatricians and palliative care agencies. These meetings have been designed to further embed the CDR process within local agencies and to identify and address any issues specific to those agencies. For example increasing understanding of how the Form B contributes to the CDR discussions and case summary.

Family follow-up

Follow-up for a family who has lost a child is an important part of the information reviewed by CDOP. Follow-up can be provided by many different agencies and can take many forms. Good follow-up includes giving the family an opportunity to meet with relevant professionals to answer questions about their child’s death, discussions around the post-mortem and Coronial process (where relevant), including discussing post mortem results and signposting them to counselling/bereavement services.

UH Bristol Trust employs a bereavement nurse, funded through the CDR process, who is responsible for ensuring that families receive appropriate follow-up, should they wish to, after the death of their child. In addition to this post the CDE Office has arranged two training sessions by the Lullaby Trust on communicating with bereaved parents for a wide range of professionals and office staff who may have contact with family members. Feedback from these training sessions has been overwhelmingly positive and those who have attended have reported that they have used the skills developed in these sessions since undertaking the training. CDOP has also recognised the differing needs of parents from a range of religious and cultural backgrounds and the need to support these families in the bereavement process. For example, the Children of Jannah is a charity that provides support to grieving Muslim families and education and training for professionals providing follow-up to them. Their information is now available through hospitals and community professionals to be passed onto Muslim families in this region.

The voice of the parents

The voice of the parents/care givers and wider family members is vital during a child’s care. CDOP has reviewed some cases in the last year where parents have found it difficult to be fully heard or informed and this has led to poor communication/integration of parents into the process of treatment for their child.  CDOP has supported ongoing discussions to improve this within the local hospital trusts and other settings.

Parents’ input after their child’s death is integral to the CDR process and opportunities are provided to all parents to enable this. The most appropriate professional in contact with the family, including the CDE office in some cases, ensure that the questions and comments of parents are presented at the local child death review meeting and fully addressed if this has not happened at an earlier stage. Parents have an opportunity to meet again with professionals following the meeting. The questions and comments of parents are also provided in the papers reviewed at CDOP.