The death of a child is a tragedy, and subsequent enquiries / investigations should keep an appropriate balance between forensic and medical requirements and the family’s need for support.

A minority of unexpected deaths are the consequence of abuse or neglect or are found to have abuse or neglect as an associated factor. Across the County of Dorset, all statutory agencies are committed to working together to conduct coordinated enquiries.

They seek to:

  • understand the reasons for each child’s death
  • address the possible needs of other children in the household
  • address the needs of all family members
  • consider any lessons to be learnt about how to prevent the death of a child

Purpose of Child Death Reviews

The Dorset Safeguarding Children Board and the Bournemouth & Poole Local Safeguarding Board have a statutory function to introduce procedures in relation to the deaths of any children normally resident in their area. The Pan Dorset Child Death Overview Panel (CDOP) was established to undertake this function on behalf of both LSCBs and is responsible for collecting and analysing information about each death with a view to identifying:

  • any case giving rise to the need for a Serious Case Review
  • any matters of concern affecting the safety and welfare of children; and
  • any wider public health concern arising from a particular death or from a pattern of deaths
  • putting into place procedures for ensuring that there is a co-ordinated response to all deaths

The Child Death Overview Panel

The Panel is responsible for reviewing the death of all children from birth (not including stillbirths) up to but not including the age of 18 years.

Chaired by Dr Vicki Fearne, Public Health Dorset, the panel also has membership from Designated Paediatric Consultants, Specialist Nurses, Local Authority and NHS Children’s Safeguarding Managers, Dorset Police, South Western Ambulance Service and the Dorset Coronial Service.

The Panel is supported by a dedicated Project Manager and Administrator and meets regularly.

Unexpected Deaths – Rapid Response Procedure

An unexpected death is defined as the death of an infant or child which was not anticipated as a significant possibility i.e. 24 hours before the death or where there was a similarly unexpected collapse leading to or precipitating the events which led to the death.

Whenever an unexpected death of a child occurs, a multi-agency response is initiated including a lead Consultant Paediatrician, a Dorset Police Senior Investigating Officer, A & E staff, ambulance staff, GPs, social care, health visitors and the Coroner to enquire into the circumstances.

A decision will be made as to which professional will take the lead. This would be the police where there are apparent suspicious circumstances or other external factors. The lead Paediatrician would usually take the lead where there are apparent health or medical factors which have resulted in the death of the child.

In addition to establishing the precise cause of death, immediate care and support will be provided to the parents or carers and other family members. The CDOP will be responsible for monitoring the appropriateness of the response of professionals to an unexpected death of a child.

Data Collection & Analysis

The Department for Education (DFE) coordinates the national data gathering procedures for every child who dies and publishes a set of templates for use by CDOPs to facilitate and standardise the local, regional and national data collection process.

The Panel will categorise the “preventability” of the death according to whether there were modifiable factors present.

  • Preventable – where a death could have been prevented if a particular action(s) had been taken
  • Potentially preventable – where there are potentially modifiable factors extrinsic to the child
  • Not preventable – the death was caused by intrinsic or extrinsic factors, with no modifiable factors

The Panel will identify any emerging learning points and record its recommendations which will be reported to the respective LSCB for consideration of appropriate action. Typically this might be the initiation of a public health awareness message, the launch of a specific campaign or working with partner agencies to improve the effectiveness or quality of their processes or procedures.

The Child Death Review process requires a number of statutory forms, these are:

  • Form A – Notification of a Child Death. Completed by any agency involved in the death of a child and forwarded to the CDOP Administrator
  • Form B – Agency Report. Completed by any professional who treated the child or who had contact with the child or family before the death. Additional reporting forms are used to collect more specific data relating to neonatal deaths, known life-limiting conditions, sudden unexpected deaths in infancy, road traffic accidents, drowning, fire / burns, poisoning, other non-intentional injury, substance misuse, apparent homicide, apparent suicide and a summary of autopsy findings.
  • Form C – Analysis Proforma. The CDOP Administrator will summarise the – collective agency reports which will be presented to the Panel whose members will consider relevant environmental, extrinsic, medical or personal factors which may have contributed to the child’s death.

For any further information about the Pan Dorset Child Death Overview Panel or the child death review process, please contact:

Pan Dorset CDOP Project Manager 01305 221825 e-mail

Pan Dorset CDOP Administrator 01305 221644 e-mail


The following documents will be of relevance: