The Joint Child Death Overview Panel for Hounslow, Kingston, and Richmond – Information for Primary Healthcare Professionals

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The Joint Child Death Overview Panel for Hounslow, Kingston, and Richmond – Information for primary healthcare professionals

Background and Purpose

It has been a statutory requirement since April 2008 that each Local Safeguarding Children Board (LSCB) must review deaths of children (under 18 years) ordinarily resident in the LSCB area. These processes are outlined in the Children Act 2004 and Chapter 5 of the Government guidance Working Together to Safeguard Children: March 2013 (WT2013).

There are two interrelated processes for reviewing child deaths:

. A rapid response by a group of key professionals who come together for the purpose of enquiring into and evaluating each unexpected death of a child . An overview of all child deaths (under 18 years) in the LSCB area(s) undertaken by a panel

The boroughs of Hounslow, Kingston upon Thames and Richmond upon Thames have joined together to undertake this function.

Through a comprehensive and multidisciplinary review of child deaths, the Joint Child Death Overview Panel (CDOP) aims to better understand how and why children in Hounslow, Kingston and Richmond die and use the findings to take action to prevent other deaths and improve the health and safety of children across the three Boroughs and the bereavement support offered to their families.

This factsheet is intended as an overview of these processes and guidance on professionals’ responsibilities in relation to them. There is a section at the end detailing sources of further comprehensive information.

The CDOP

The Joint CDOP has a permanent core membership drawn from the key organisations represented on the LSCBs of each authority area. Other members may be co-opted to contribute to the discussion of certain types of death when they occur, and will also welcome observers. Core membership will consist of senior representatives as follows (for each Borough):

Public Health Associate Director or Consultant; Designated Paediatrician for unexpected deaths in childhood; Health safeguarding representative, Designated/Named Nurse for Safeguarding Children; Detective Inspector, Child Abuse Investigation Team (CAIT), Metropolitan Police Service; and Local Authority Safeguarding Managers; The Panel will also, where possible, have a representative of a bereavement agency or similar.

The Panel is chaired by a representative from one of the three borough’s Public Health Teams on a yearly rotating basis. The Chair is a member of each of the three LSCBs.

The Panel meets bi-monthly.

All information relating to individual children presented to the panel for the purpose of reviewing their death is anonymised. All professionals taking part in panel meetings are required to sign a confidentiality statement.

The designated person for Hounslow, Kingston and Richmond’s Local Safeguarding Children Boards (Joint CDOP Coordinator)

The designated person for each of the three LSCBs to whom all information or queries relating to the child death review function is the CDOP Coordinator, based at the London Borough of Richmond upon Thames. Contact details are provided at the end of this factsheet.

Contribution of professionals

. Notification of child deaths

When a child dies it is the responsibility of the doctor certifying their death to complete the Initial Notification Form A and submit this securely within 24 hours of the death (for example via confidential fax or secure e-mail) to the designated person. There are instances where children die outside a hospital setting, for example at home. In this instance where GPs are responsible for certifying a child’s death they must also notify the death to the LSCB via the designated person. There may also be occasions on which primary healthcare professionals may be made aware of a death that may not have been notified but for which they were not involved in the certification, for example deaths abroad. We would ask that in this instance you contact the designated person who will advise you on whether an Initial Notification Form A is required.

The Joint CDOP Initial Notification Form A template can be obtained via the designated person, or via the local hospital paediatric team if out of hours.

. Form B Agency Reports

In order to establish a comprehensive understanding of the cause, circumstances and wider context of a child’s death and the services provided to them and their families in relation to this, the CDOP will request completion of Form B Agency Reports by all professionals/agencies involved with a child prior to or at the time of their death. These requests will be made in writing and the Form B for completion will be attached. Unless advised otherwise in the letter of request, the timescale for completion and return of these agency reports is three weeks from receipt of the request (as advised in WT2013). The contribution from primary healthcare professionals via Agency Report Form Bs is very important and should also include any details regarding bereavement support for the family provided by or accessed via your agency, as well as the child’s previous medical history (and the involvement of other professionals) and the family context. Issues regarding service provision and any other matter that you would like brought to the Panel’s attention for their consideration, can also be raised on this form.

Should you have any queries regarding completion of these forms then please contact the designated person for further advice.

. Rapid Response

As noted in the introduction, when a child’s death is unexpected1 a rapid response is initiated. As part of the rapid response process, one or more multiagency meetings may be convened to

1 An unexpected death is defined as a death of a child under 18 years which was not anticipated as a significant possibility for example, 24 hours before the death; or where there was a similarly unexpected collapse or incident leading to or precipitation the events which led to death.

gather and share information and evaluate the cause and circumstances of the child’s death, identify any concerns or requirement for parallel processes such as a serious case review, and to coordinate support and follow-up for their family. The initial rapid response meeting will generally be held within a fortnight of the child’s death. Relevant primary healthcare professionals will be invited to attend this meeting in writing and should try to attend. Where you are unable to attend we may ask for a Form B and any other information as necessary before the meeting, to ensure this information can be taken into consideration at this time.

. Involvement of families and carers

The LSCB has a responsibility to inform families about the review process and to facilitate their contribution should this be desired by them. In the hospitals and hospice within the Joint CDOP area there are arrangements for the provision of information, including our leaflet and verbal information, to be given to families by the relevant professionals involved with their child’s death. Where children die outside hospital e.g. at home or abroad, it becomes the responsibility of the primary health care team to inform families about the child death review process at an early stage and it may be helpful to give parents our leaflet (copies can be obtained via the CDOP Coordinator). This is then supplemented by a letter from the CDOP Chair with accompanying leaflet, which is sent to all families approximately two months after a child’s death. This letter and leaflet explain the review process and families are invited to contact the CDOP to contribute to the review should they wish. The CDOP is aware that this is a sensitive matter and that families may require the support of a professional known to them in order to understand and/or contribute to this process. This letter is therefore copied to the family GP. If in your role as primary healthcare providers you or families you are supporting have any questions, comments or concerns in relation to this process, then please contact the designated person for assistance.

. Recommendations

The CDOP is responsible for considering as part of the review process whether there are any recommendations that could be made to assist in the prevention of other deaths and to improve the health and safety of children throughout the three boroughs. In some instances the Panel may identify specific follow up that would benefit an individual family and may write letters of recommendation to the GP or Health Visitor in relation to this. These actions may also be identified as part of the rapid response process where applicable. There may also be broader learning and initiatives relating to this for which we will ask for your cooperation.

Further information

Government Guidance to the child death review process can be found in the following:

. Working Together to Safeguard Children: March 2013 A guide to inter-agency working to safeguard and promote the welfare of children

The specific chapter relating to the child death review processes is chapter 5.

Please do not hesitate to contact the CDOP Coordinator for any additional information or support.

The designated person, Coordinator for the Joint CDOP, can be contacted via the following:

Tel: 020 8831 6257

Fax: 020 8891 7719

E-mail: [email protected] Secure e-mail (*compatible with nhs.net accounts): [email protected]

You can contact the CDOP Chair, CDOP Manager and the Designated Paediatricians for the respective boroughs via the CDOP Coordinator.

The CDOP welcomes observers. If you wish to attend please contact the CDOP Coordinator to make arrangements for this.