Child Death Review Arrangements

Accountable Officer-CEO Leeds Health and Care Partnership

ICS Lead- Executive Director of Quality and Safety/Governing Body Nurse-Leeds Health and Care Partnership

Designated Nurse- Head of Safeguarding/Designated Nurse Safeguarding Children and Adults

Leeds Safeguarding Children Partnership Lead- LSCP Business Manager


Chapter 5 of Working Together to Safeguard Children 2018 (WTSC) published in July 2018, outlined changes to the child death review process. The government produced a more comprehensive Child Death Review Statutory and Operational Guidance in October 2018 and set out key features of what a good Child Death Review (CDR) process should look like and the statutory requirements that must be followed.


“Child death review partners” as defined in section 16Q of the Children Act 2004 include the local authority and any Leeds Health and Care Partnership for an area, any part of which falls within the local authority area.

The two partners must make arrangements for the review of each death of a child normally resident in the area. They must also make arrangements for the analysis of information about deaths reviewed under the new guidance.

Senior leaders within organisations who commission or provide services for children in Leeds, as well as relevant regulatory bodies, should also follow the procedures set out in the guidance.

All other professionals who care for children, or who have a role in the Child Death Review process, should read and follow the guidance so that they can respond to each child death appropriately.

Geographical Area

In agreement with the other West Yorkshire Child Death Overview Panel (CDOP) Chairs, the geographical footprint for reviewing child deaths will sit within the boundaries of Leeds. If the child received the majority of their services in another local authority area, an agreement will be reached between relevant CDOPs as to who will review the death.


All deaths in Leeds that fit the criteria under the Child Death Review Operational Guidance will be notified to the Designated Administrator for the Child Death Overview Panel, located within the LSCP Business Unit.

Standard CDOP forms, provided by the Department of Education, will be used in the Child Death Review process, to gather relevant information for reviewing individual deaths.

Criteria for Reviewing a Child Death

The deaths of all children who are normally resident within the boundaries of Leeds local authority will be reviewed under these arrangements, including live born babies where a death certificate has been issued (including under 22 weeks).

In the event that the birth is not attended by a healthcare professional, Child Death Review partners may carry out initial enquiries to determine whether or not the baby was born alive. If these enquiries determine that the baby was born alive the death must be reviewed.

Cases where there is a live birth after a planned termination of pregnancy carried out within the law are not subject to a child death review.

In circumstances where a child has died and abuse or neglect is known or suspected, professionals at the initial information-sharing and planning meeting should notify the safeguarding partners whose responsibility it is to determine whether the case meets criteria for a Child Safeguarding Practice Review (CSPR).

Child Death Review process

Chapter 6 and 7 of the Child Death Review Statutory and Operational Guidance lays out the responsibilities for Health and the Local Authority, where Chapter 8 lays out the responsibility for the CDOP.

Joint Agency Response (JAR)

A JAR will be triggered in full for all child deaths that are sudden or unexpected.
An unexpected death is a term used at presentation for the death of an infant or child whose death was not anticipated as a significant possibility 24 hours before the death, or where there was a similarly unexpected collapse leading to or precipitating the events which led to the death.

Sudden and Unexpected Death in Infancy and Childhood: multi-agency guidelines for care and investigation (2016) provides clear guidance on the process that should commence following the unexpected death of a child.

Child Death Review Meeting (CDRM)

The CDRM is a multi-agency meeting where all matters relating to an individual child are discussed by professionals directly involved in the care of that child during their life.

The CDRM will review the deaths of all children and will output a draft ‘Analysis Pro Forma’ which will be sent to the CDOP. Exceptions to this are:

  • Where the death of a child was unexpected and the SUDIC guidelines were followed. The SUDIC minutes and final report will be sent directly to CDOP.
  • Where the death is of a baby <28 days old, a completed Perinatal Mortality Review Form (PMRT) will be provided to CDOP.
  • Where the death is subject to a CSPR, the CDOP will accept the full report.

Leeds Child Death Overview Panel (CDOP)

The deaths of all children that fit the criteria laid out in WTSC and the supplementary Child Death Review guidance will be reviewed by the CDOP. Leeds safeguarding partners that form the core membership of the CDOP will include, but is not limited to:

  • LCC Adults & Health Deputy Director of Public Health (Chair)
  • Leeds Safeguarding Children Partnership Manager
  • West Yorkshire Police Serious Case Review Officer
  • LCC Children’s Services Head of Children’s Social Work Service
  • LCC Children’s Services 0-11 Safeguarding Coordinator
  • Leeds Community Healthcare NHS Trust SUDIC Paediatrician
  • Leeds Community Healthcare NHS Trust SUDIC Professional Lead (Nursing)
  • Leeds Community Healthcare NHS Trust Service Manager for Health Visiting
  • NHS Leeds Health and Care Partnership Designated Doctor
  • NHS Leeds Health and Care Partnership Designated Nurse
  • Leeds Teaching Hospitals NHS Trust Head of Nursing (Children)
  • Martin House Hospice Director of Clinical Services
  • Educational representative
  • Leeds Partnerships NHS Foundation Trust Consultant Psychiatrist & Named Doctor for Safeguarding Children

Other agencies and organisations may be co-opted for specific deaths if appropriate and agreed by the Chair of the CDOP.

LSCP Business Unit

The LSCP Business Unit, funded through the LSCP Executive, will facilitate and support the CDOP process.

Annual Report

The CDOP, through its Designated Doctor and the Chair, will publish an annual report for the LSCP Executive on local patterns and trends in child deaths, any lessons learnt and actions taken, and the effectiveness of the wider Child Death Review process. This report will be available on the LSCP Website for a period of 12 months.


Children are defined under the Children Act 2014 as a person under 18 years of age.
WTSC 2018 Chapter 4.18. The criteria and guidance when determining whether to carry out a local child safeguarding practice review.
Sudden unexpected death in infancy and childhood-Royal College of Paediatrics and Child Health November 2016.

Quick leave