Child deaths and the Child Death Overview Panel (CDOP)

Every child death is a tragedy for the family and the wider community. Deaths of all children, up to the age of 18 years, need to be reviewed, taking into account all available information for each death.

Reporting a child death

All Local Safeguarding Children Boards are required to have a Child Death Overview Panel (CDOP) to determine whether we can learn lessons from child deaths, in order to improve the health, safety and wellbeing of other children. Through this, we hope to prevent further child deaths.

If you are a professional seeking to report a child death you should do so via the eCDOP online portal.

Cambridgeshire and Peterborough child death review queries can be sent via the single point of contact:

The Child Death Overview Panel (CDOP) is responsible to the Cambridgeshire and Peterborough Safeguarding Children Board for reviewing information on all child deaths, looking for possible patterns and potential improvements in services, with the aim of preventing future deaths.

CDOP’s statutory duties are laid out in Working Together 2018 as follows:-

Statutory Requirements

When a child dies, in any circumstances, it is important for parents and families to understand what has happened and whether there are any lessons to be learned.

The responsibility for ensuring child death reviews are carried out is held by ‘child death review partners,’ who, in relation to a local authority area in England, are defined as the local authority for that area and any clinical commissioning groups operating in the local authority area.

Child death review partners must make arrangements to review all deaths of children normally resident in the local area** and, if they consider it appropriate, for any non-resident child who has died in their area.

Child death review partners for two or more local authority areas may combine and agree that their areas be treated as a single area for the purpose of undertaking child death reviews.

Child death review partners must make arrangements for the analysis of information from all deaths reviewed.

The purpose of a review and/or analysis is to identify any matters relating to the death, or deaths, that are relevant to the welfare of children in the area or to public health and safety, and to consider whether action should be taken in relation to any matters identified. If child death review partners find action should be taken by a person or organisation, they must inform them. In addition, child death review partners:

  • Must, at such times as they consider appropriate, prepare and publish reports on:
    • What they have done as a result of the child death review arrangements in their area; and
    • How effective the arrangements have been in practice.
  • May request information from a person or organisation for the purposes of enabling or assisting the review and/or analysis process – the person or organisation must comply with the request, and if they do not, the child death review partners may take legal action to seek enforcement; and
  • May make payments directly towards expenditure incurred in connection with arrangements made for child death reviews or analysis of information about deaths reviewed, or by contributing to a fund out of which payments may be made; and may provide staff, goods, services, accommodation or other resources to any person for purposes connected with the child death review or analysis process.

* The guidance in this chapter is issued under section 16Q of the Children Act 2004. Further guidance on child death review procedures will be issued by the government. While the contents of this chapter will be duplicated within that document, child death review partners should also have regard to that guidance to assist in their understanding of the steps taken by others prior to the child death reviews and analysis they carry out.
** For the purposes of child death reviews, a local area is the area within the remit of a local authority (referred to in the Act as a “local authority area”).

The functions of CDOP include:
  • to collect and collate information about each child death, seeking relevant information from professionals and, where appropriate, family members;
  • to analyse the information obtained, including the report from the CDRM, in order to confirm or clarify the cause of death, to determine any contributory factors, and to identify learning arising from the child death review process that may prevent future child deaths;
  • to make recommendations to all relevant organisations where actions have been identified which may prevent future child deaths or promote the health, safety and wellbeing of children;
  • to notify the Child Safeguarding Practice Review Panel and local Safeguarding Partners when it suspects that a child may have been abused
    or neglected;
  • to notify the Medical Examiner (once introduced) and the doctor who certified the cause of death, if it identifies any errors or deficiencies in an individual child’s registered cause of death. Any correction to the child’s cause of death would only be made following an application for a formal correction;
  • to provide specified data to NHS Digital and then, once established, to the National Child Mortality Database;
  • to produce an annual report for CDR partners on local patterns and trends in child deaths, any lessons learnt and actions taken, and the effectiveness of the wider child death review process; and
  • to contribute to local, regional and national initiatives to improve learning from child death reviews, including, where appropriate, approved research carried out within the requirements of data protection.

Guidance and Protocols


CDOP Annual Report