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Child death reviews: improving the use of evidence

The concept of child death reviews is not a new one; systems for review have been set in place in a number of countries including in the US where reviews were established in some States in the late 1970s (Johnson & Covington 2011). In the UK particular types of child deaths have been reviewed for some time in some regions, for example the Avon area (Fleming et al, 2004), and some deaths were reviewed in specific regions as part of the CEMACH ‘Why Children Die: A Pilot Study’ (Pearson 2008).

Enshrined in national legislation for the first time in England, Local Safeguarding Children Boards (LSCBs) were required to establish local Child Death Overview Panels (CDOPs) by April 2008, and subsequent national guidance and regulations have served to unify some operational aspects (Working Together to Safeguard Children, 2010) with the guidance having been recently updated (Working Together to Safeguard Children, 2013). Under the Children Act (2004) all Local Authorities in England have a statutory duty to set up a CDOP to review the deaths of all children from birth up to 18 years of age who are normally resident in their area. CDOPs are the responsibility of Local Safeguarding Children Boards (LSCBs) and some LSCBs ‘share’ CDOPs thus (at the time of writing) there were 93 CDOPs responsible to 148 LSCBs; on-going amalgamations mean that the exact number is difficult to specify at any one point in time. Central Government responsibility and oversight is located in the Department for Education.

The primary purpose of CDOPs is to review individual deaths, to identify modifiable causes to inform strategic planning on how “best to safeguard and promote the welfare of the children in their area” (Working Together to Safeguard Children, 2010) – that is, to learn lessons and put the lessons into practice to prevent future deaths. To meet these ends and to support the operational functions of the CDOP each CDOP collects information about each child death in their area including the conclusions of the panel review. A series of data collection templates for use by CDOPs are provided by the DfE and are available to download from the DfE website (Department for Education, 2013). Aggregated anonymised data are submitted once each year to the Department for Education who report each year’s data centrally on an annual basis. Individual CDOPs report their own data in their own annual report, some of which make a public version available. The quality of data returned and the proportion of child deaths reviewed have improved year on year (Department for Education, 2012). Evidence of local actions and their impact comes from reviewing individual CDOP annual reports, conference presentations (FSID conference, 2012) and from the published literature (Sidebotham et al, 2011).