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Child Death Review programme

There is a national requirement that all child deaths are reviewed, for which there are approximately 700 each year in London.

The Children and Social Work Act (2017) and subsequent statutory guidance outlines changes to the bodies responsible and the process of safeguarding children and reviewing child deaths. In May 2019, NHS England published a statement on the transition arrangements to the Child Death Review section of the Future NHS Collaboration platform website.

Healthy London Partnership’s Child Death Review (CDR) Programme supports London CCGs and local authorities (Child Death Review Partners) and specifically those involved in Child Death Review Meetings (CDRMs) and Child Death Overview Panels (CDOPs), to understand and meet the new requirements, maximise their impact in the prevention of child deaths, and learn lessons to improve services for children and their families. The programme is currently funded until September 2019.

Key dates include:

1 April 2019

The National Child Mortality Database (NCMD) went live. Department of Health & Social Care transitional arrangements outline that from 1st April, all new child deaths and any open cases (those not yet reviewed by a child death overview panel) of children who died before that date should be added to the NCMD. The data collection requirements to support the review of each child’s death also changed on this date, see the gov.uk website for further information.

29 June 2019

Local authorities & CCGs (new Child Death Review Partners) in England must publish their plans to meet the new requirements and submit them to NHS England at England.cypalignment@nhs.net. NHS England have developed a non-mandatory template to support CDRPs with the development and submission of their plans.

29 September 2019

CDRPs in England must complete the transition to the new arrangements. After this date they must be compliant with the new statutory requirements.

Pan-London access to eCDOP child death review case management system April 2018-March 2020

In 2018 NHS Digital funded pan-London access to the child death review online case management system, e-CDOP, developed by QES, for all London CDOPs until 31st March 2019. HLP facilitated the roll-out and adoption of eCDOP to the London CDOPs. Following feedback from child death review stakeholders across London, the public health commissioning team at NHS England (London Region) agreed to provide 12 months non-recurrent funding to support continued access to eCDOP for the London CDOPs. HLP will continue to manage the contractual arrangements with QES during this time.

All London CDOPs will therefore be able to continue to use eCDOP without charge between 1st April 2019 – 31st March 2020. However, from 1st April 2020, local CDRPs will need to fund any solution locally. There will be no further central (London) funding for eCDOP beyond this point.

Tools, resources and shared learning

  • HLP supported one and ran four London STP sector workshops between January – March 2019 to support child death review professions in London come together and discuss the challenges, considerations and potential solutions to meet the new statutory requirements. The Child Death Review Information pack, originally published in February 2019, has been updated to outline progress towards the new statutory requirements across London. It also provides useful background and contextual information to support local discussions. The discussions and outputs from the workshops are summarised here.
  • HLP is developing an eLearning package to support child death review professionals develop an understanding of the process and requirements. This will be available from August 2019. 
  • HLP has been working with NHS England (London Region) and bereavement leads and families to develop a resource to guide professionals collecting feedback locally on the bereavement care of families and carers following the loss of a child. This will include a Bereavement Experience Measure which will build on the success of the Maternity Bereavement Experience Measure (MBEM) and is intended to be available from June 2019.
  • The team will continue to meet with stakeholders across London to share thinking and best practice about child death reviews and support the London Child Death Overview Panel (CDOP) Chairs Network.

Memorandum of Understanding with London Coroner

We have worked with HM Coroner for Inner South London Dr Andrew Harris, and colleagues from health and police across South East London to agree a single pathway to guide health professionals in the aftermath of managing the unexpected death of a child. This includes a memorandum of understanding from the Coroner’s officer pre-authorising certain processes after the death of a child; guidance for practitioners on statutory processes; and resources for bereavement support.

While it carries legal weight only within the Inner South London jurisdiction of Coroner Harris, we would encourage other areas to work with their stakeholders (coroners, police, hospital and community trusts, ambulance services) to use this as a template and develop and agree their own local versions in order to reduce the unnecessary variation in practice after a child’s death.

This work builds on the excellent South West London pathway which was agreed in 2018. We hope that other coronial jurisdictions will, if appropriate, agree local guidance along these lines.

More information

If you have any queries about the CDR Programme, please email David McKinlay, Child Death Review Programme Manager.

The CDR Programme is led by Dr Ronny Cheung, Clinical Director, and Dr Donal O’Sullivan, Clinical Advisor.

Useful links

Related national programmes

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