Child death overview panels: how have the pilots performed?

Local safeguarding children boards must review all child deaths in their areas. The new child death overview panels, together with serious case reviews and the new rapid response procedure form the principal tools for investigating children’s deaths.

Invariably it is child deaths that have elements of abuse and neglect which attract the most publicity, as we are now witnessing with news of seven-year-old Khyra Ishaq’s death in Birmingham. But each year thousands of children also die from causes ranging from sudden unexpected infant death to suicide. Often these deaths pass with little mention, but the launch last month of child death overview panels will see all deaths scrutinised.

AmyThe panels consist of a set of public sector professionals (see How they are made up) who will analyse information gathered about the child from before and immediately after their death.

They have their own chairs but are accountable to the chair of the local safeguarding children boards (LSCBs), on which the requirement is placed to review all child deaths in their area. Some will work across a number of the 150 boards in England, depending on the size of the areas covered, and aim to identify why children are dying and use this information to prevent further deaths and spot trends.

A multi-agency research team, led by the University of Warwick, has been evaluating the new child death review processes in nine pilot sites in England and its research is due soon. Dr Peter Sidebotham, associate professor in child health at Warwick who led the team, says he is aware of 66 that are working in collaboration and predicts more will collaborate than not.

Harrow pilot

Harrow, west London, was one of the nine pilot sites. It set up its panel some three years ago as it wanted to improve its multi-agency arrangements in regard to child deaths. The panel, chaired by a consultant paediatrician, includes a representative from The Foundation for the Study of Infant Deaths, a charity that looks at cot death.

Betty Lynch, strategic development manager for Harrow’s local safeguarding children board, says the panel plays a valuable role and could lead to fewer children dying.

“It’s [about asking] why are children dying? What’s the reason for their deaths and what can we do about it?” she says. “If you sort your statistics out and get organised you can provide the evidence for strategic development [of preventive policies] and it could actively reduce child deaths in time.”

When child protection issues are a factor in a death a serious case review will still be held. The panel will consider the findings and challenge them if necessary. The panel will also refer any deaths they believe could require such a review to the LSCB chair as well as any further enquiries that it feels should be made.

Sidebotham says: “The panel provides a safety net in terms of being able to review the cases. Issues may come up which haven’t been picked up earlier and these then get referred to the chair of the LSCB, the coroner or the police for further investigation.”

Serious case reviews look at specific actions by professionals and parents. The panel’s aim is not to duplicate this work but to consider whether reviews support wider trends, such as the incidence of children of drug abusing parents dying in a particular area.

As well as using the information locally, the panels are required to provide information nationally to inform government policies. For this to happen they must collect their information according to a nationally agreed minimum data set. The Department for Children, Schools and Families is yet to confirm how it intends to collect this but the Warwick researchers say it is likely to be based on a tool used by the Confidential Enquiry into Maternal and Child Health (Cemach).

West of England panel

Child death pieceThe West of England Child Death Overview Panel serves four LSCBs across the region (see Pilot panel). It uses Cemach to provide it with basic information on each death, packaged up in a format the panel can then review.

Ian McDowall, programme director of Bristol Children and Young People’s Service (safeguarding) and panel chair says the decision to establish a panel covering more than one LSCB area makes it easier to spot trends. “One thing we are going to do is look at themes (such as suicide) and we will approach the information in that way. [In order to do this type of work] it’s good that we have expanded to cover an area of about a million people,” he says.

Ever increasing paperwork is a constant gripe raised by children’s services professionals and it is easy to see how the introduction of what’s potentially another level of bureaucracy could be met with scepticism.

Lynch says it is essential that members see evidence of panels’ information being used by government to guard against this. “Otherwise people are going to think there’s no point in doing this,” she says.

The level of commitment some agencies show towards LSCBs has been questioned by research. Lynch says Harrow had previously conducted a programme to ensure each LSCB member was clear on their role.

Coroner’s sytem reform

Last November, the government unexpectedly failed to include a bill to reform the coroner’s system in the Queen’s Speech. The NSPCC warned that the delay could lead to panels lacking information from coroners who are not currently compelled to share information. Government guidance decrees that there should be agreed channels of communication between panels and coroners but Sidebotham says that, although coroners were engaging with panels in most areas, this varied across the country.

The evaluation found that professionals were enthusiastic about the panels and Sidebotham says that, with commitment at a local level, they could lead to a reduction the number of child deaths.

He says: “Studies conclude that in 15-30% of child deaths you can identify avoidable factors. If you can identify those factors and have local motivation to do something about them then you can make a difference to child mortality.”

Rapid response procedures

These form the other part of the new processes for dealing with child deaths.

When a child dies unexpectedly new procedures now kick in to support parents and try and work out the potential causes. Under the plans professionals involved (before or after the death) with a child who dies unexpectedly come together to investigate and evaluate what has taken place.

This will usually be co-ordinated by a local designated paediatrician who is responsible for unexpected child deaths in an LSCB area. Such teams could have standing members or a team of professionals on an on-call rota for responding to unexpected deaths. Professionals likely to come together in such a team include paediatricians, GPs, nurses, health visitors, midwives, mental health professionals, social workers, probation and the police.

They will also work according to a joint protocol agreed with their local coroner’s office.

The government’s guidance on the teams, included in chapter 7 of Working Together to Safeguard Children, lists their responsibilities as the following:

1. Responding quickly to the unexpected death of a child.

2. Making immediate enquiries into and evaluating the reasons for and circumstances of the death, in agreement with the Coroner.

3. Undertaking the types of enquiries/investigations that relate to the current

responsibilities of their respective organisations when a child dies unexpectedly.

4. This includes liaising with those who have ongoing responsibilities for other family members.

5. Collecting information in a standard, nationally agreed manner.

6. Following the death through and maintaining contact at regular intervals with family members and other professionals who have ongoing responsibilities for other family members, to ensure they are informed and kept up-to-date with information about the child’s death.

Raid response procedures and a child death overview panel were introduced in Harrow, West London, around three years ago, prior to the government guidance being published, due to the council wanting to improve its procedures around child deaths. Betty Lynch, strategic development manager for Harrow’s local safeguarding children board, says that under their rapid response procedures the duty team or emergency duty team will always be informed when a child unexpectedly dies but may not necessarily be involved.

“It doesn’t always involve a social worker going down to A&E. In collaboration with the doctor, social care will decide if they need to be involved. If it’s overtly child abuse child protection procedures will be activated straight away. The main concern is if there are siblings of the family who need support.

“Social care has a very important role if there are siblings. If you think there are no problems and social care checks and the children are on the register that’s a different story,” she says.


Government guidance on panels and rapid response procedures is contained in chapter 7 of Working Together to Safeguard Children

 Early findings from the evaluation

 More on LSCBs from Community Care

Published in Community Care magazine under the headline ‘Why are these children dying?’

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