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Child Death Review: Statutory and Operational Guidance (England)

This guidance sets out key features of what a good child death review process should look like. This process combines best practice with statutory requirements that must be followed.

The purpose of setting out key features of a robust child death review process in one document is to ensure that the outputs from reviews are standardised as far as possible and of a uniform quality. This will enable effective thematic learning from reviews, i.e. a local review may be able to identify specific learning but trends analysis at a national level may identify modifiable factors that could be altered to prevent future deaths. This requires a degree of standardisation that this document aims to outline; however, clinical commissioning groups (CCGs) and local authorities (the child death review partners) are able to make arrangements for child death reviews as they see fit in order to meet the statutory requirements under the Children Act 2004 (the Act).

The process set out in this document runs from the moment of a child’s death to the completion of the review by the Child Death Overview Panel (CDOP) or any equivalent arrangements put in place by child death review partners. This includes the immediate actions that should be taken after a child’s death; the local review of a child’s death by those who interacted with the child during life, and with the investigation after the child’s death; through to the final stage of the child death review process which is the statutory review arranged by child death review partners.

The process is designed to capture the expertise and thoughts of all individuals who have interacted with the case in order to identify changes that could save the lives of children.