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

The Pan Berkshire (LSCB) Child Death Overview Panel is the collaboration of six LSCBs joining together on a wider multi-agency platform to work in partnership. This allows for sharing of good practice and development of safeguarding opportunities towards improving outcomes for all children and young people across the Berkshire area.

About Rapid Response

Rapid Response is an inter-related process  for reviewing child deaths whereby a team of key professionals come together for the purpose of enquiring into and evaluating each unexpected death of a child.

The Berkshire Rapid Response Procedures and associate appendices explain this process more fully:

About CDOP

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

Function of CDOP

The key functions of a CDOP are to:

  • review all child deaths, excluding those babies who are stillborn and planned terminations of pregnancy carried out within the law
  • determine whether the death was preventable (if there were modifiable factors which may have contributed to the death)
  • decide what, if any, actions could be taken to prevent such deaths happening in the future
  • identify patterns or trends in local data and report these to the LSCB Chairs
  • refer cases to the LSCB Chairs where there is suspicion that neglect or abuse may have been a factor in the child’s death. In such cases a Serious Case Review may be required.
  • agree local procedures for responding to unexpected child deaths


The Pan Berkshire Local Safeguarding Children Boards’ (LSCB) sub-groups are the collaboration of six LSCBs joining together on a wider multi-agency platform to work in partnership.  This allows for sharing of good practice and development of safeguarding opportunities to improve outcomes for all children and young people across Berkshire.

These are the terms of reference that apply to the Pan Berkshire Child Death Overview Panel (CDOP).  The Child Death Overview Panel was established in April 2008 and is a sub-group of each Berkshire Local Safeguarding Children Board (LSCB).   The government requires each LSCB to carry out a review of all child deaths in their area, following the processes set out in Working Together to Safeguard Children (2015).


Through a comprehensive and multidisciplinary review of child deaths, the CDOP aims to better understand how and why children in Berkshire die and use the findings to take action to prevent other deaths and improve the health and safety of children within Berkshire.

In carrying out activities to pursue this purpose, the CDOP will meet the functions set out in Working Together to Safeguard Children (Chapter 5) in relation to the death of any children who are residents of the borough.

(a)  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 in the area.
  • Any wider public health or safety concerns arising from a particular death or from a pattern of deaths.

(b)  Establishing procedures for ensuring a coordinated response to an unexpected child death.


Notification and data collection

The Pan Berkshire CDOP will seek to do the following:

  • Ensure in consultation with the local Coroner’s office, that local procedures and protocols are developed, implemented and monitored, in line with the guidance in chapter 7 of Working Together 2010 on enquiring into unexpected deaths.
  • Ensure the accurate identification of and uniform, consistent reporting of the cause and manner of every child death.
  • Collect and collate an agreed minimum data set of information on all child deaths in the area, and where relevant, seek additional information from professionals and family members.
  • Determine those deaths in which modifiable factors may have contributed to the death and decide what, if any, actions could be taken to prevent future (or reduce the risk of) of such deaths.
  • Co-operate with regional and national initiatives to identify lessons on the prevention of unexpected child deaths e.g. national learning from information about child deaths initiative.
  • Make recommendations to the LSCB and/or other relevant bodies promptly so that action can be taken to prevent future such deaths where possible.

Case level

The CDOP will seek to:

  • Evaluate specific cases in depth, and identify any issues of concern or lessons to be learnt.
  • Where concerns of a criminal or child protection nature are identified, ensure that the police and coroner are aware and to inform them of any specific new information that may influence their inquiries: to notify the Chair of the LSCB of those concerns and advise the chair on the need for further enquiries under section 47 of the Children Act or of the need for a serious cases review.

Population level, prevention and advocacy

The CDOP will seek to:

  • Evaluate data on the deaths of all children normally resident in the local area, thereby identifying lessons to be learnt or issues of concern, with a particular focus on effective inter-agency working to safeguard and promote the welfare of children.
  • Identify significant risk factors and trends in individual child deaths and in overall patterns of deaths in the local authority areas, including relevant environmental, social, health and cultural aspects of each death, and any systemic or structural factors affecting children’s well being to ensure a thorough consideration of how such deaths might be prevented in the future.
  • Identify any public health issues and consider with the Directors of Public Health, and other professional agencies, on how best to address these and their implications for both the provision of services and for training.
  • Identify and advocate for needed changes in legislation, policy and practices to promote child health and safety and to prevent child deaths.
  • Increase public awareness and advocacy for the issues that affects the health and safety of children.
  • Where a suspicion arises that neglect or abuse may have been a factor in the child’s death, refer a case back to the LSCB Chair for consideration of whether an SCR is required and understand the reasons why that decision was taken.

Service improvement

The CDOP will seek to:

  • Identify areas of improvement in agency responses to child deaths through monitoring the appropriateness of the response of professionals to each unexpected death of a child.
  • Agree local procedures for responding to unexpected deaths of children and receive assurance that they are in place and in line with national regulations.
  • Provide relevant information to those professionals involved with the child’s family so that they, in turn, can convey this information in a sensitive and timely manner to the family, (for example should the family require genetic testing for consanguinity).
  • Identify and inform the LSCB on the resources and areas where training may be required to improve an effective inter-agency response to child deaths.


The Panel will review all child deaths (at 23 weeks gestation up to their 18th birthday) of children normally resident within Berkshire at the time of death (excluding those babies who are stillborn, and planned terminations of pregnancy carried out within the law).

This will include neo-natal deaths, expected and unexpected deaths in infants and in older children.  Where a child, normally is resident in another area, dies within the area, that death shall be notified to the CDOP in the child’s area of residence. Similarly, when a child normally resident in the area dies outside the local authority area, the CDOP should be notified. In both cases an agreement should be made as to which CDOP (normally that of the child’s area of residence) will review the child’s death.   In both cases, an agreement should be made as to how the two CDOPs will report to each other.

Panel membership

As Working Together 2015 states the Pan Berkshire Child Death Overview Panel will have a permanent core membership drawn from the key organisations represented from each of the six LSCBs.   Other members may be co-opted to contribute to the discussion of certain types of death when they occur.

Pan Berkshire specific representation:

  • CDOP Chair
  • Pan Berkshire CDOP Coordinator

Core membership will consist of senior management representatives of the following (for each Borough-East and West):

  • Designated Paediatrician/Designated Health Professional
  • Public Health Representative
  • Police Representative
  • Ambulance Service Representative
  • Local Safeguarding Children Board Business Manager – host and local Representative where case relevant
  • Children’s Social Care Representative
  • Bereavement Representative
  • Berkshire East/West Clinical CCG Representative
  • Berkshire Healthcare Foundation Trust (BHFT) Representative

All agencies must arrange appropriate alternative means of representation for meetings they cannot attend.

For the meeting to be quorate there needs to be a representative from each of the core disciplines of the Child Death Overview Panel.  This is the minimum representation for any meeting to take place.

The panel meeting will be deemed to be quorate if there is representation from:

  • Director of Public Health (Chair) or Deputy Chair
  • Designated/Named nurse for safeguarding children, CCG
  • Protecting Vulnerable People Thames Valley Police, Berkshire
  • Local Authority Safeguarding Manager
  • Designated paediatrician for unexpected deaths in childhood

The CDOP Panel is chaired by Lise Llewellyn, Strategic Director of Public Health.

The Vice Chair is Rachael Wardell, Corporate Director, Communities West Berkshire.

The role of each core CDOP member:

The Public Health representatives can:

  • Provide the panel with information on epidemiological and health surveillance data.
  • Assist the panel in strategies for data collection and analysis.
  • Assist the panel in evaluating patterns and trends in relation to child deaths and in learning lessons for preventive work.
  • Inform the panel of public health initiatives to support child health.
  • Advise the panel on the development and implementation of public health prevention activities and programmes.

The Paediatrician can:

  • Provide the panel with information on the health of the child and other family members, including any general health issues, child development, and health services provided to the child or family.
  • Help the panel interpret medical information relating to the child’s death including offering opinions on medical evidence, provide a medical explanation and interpretation of the circumstances surrounding a child’s death.
  • Assist with interpreting the autopsy findings and results of medical investigations.
  • Advise the panel on medical issues including child injuries and causes of child deaths, medical terminology, concepts and practices.
  • Chair rapid response meetings and provide assistance and support in the rapid response process.
  • Provide feedback and support to medical practitioners involved in individual case management.
  • Liaise with other health professionals and agencies, where there are child protection concerns.
  • Present cases and concerns to the CDOP.
  • Liaise with families, when deemed appropriate.

Police representatives can:

  • Provide the panel with information on the status of any criminal investigation.
  • Provide the panel with information on the criminal histories of family members and suspects.
  • Identify cases that may require a further police investigation
  • Provide the panel with expertise on law enforcement practices, including investigations, interviews and evidence collection.
  • Help the panel evaluate any issues of public risk arising out of the review of individuals’ deaths.
  • Liaise with other police departments, and the Crown Prosecution Service.
  • Provide feedback to police officers involved in individual case management.

Children’s Social Care representatives can:

  • Provide the panel with information on any social care involvement with the child and family, including any child protection concerns.
  • Help the panel to evaluate issues relating to the family and social environment and circumstances surrounding the death.
  • Advise the panel on children’s rights and welfare, and on appropriate legislation and guidance relating to children.
  • Identify cases that may require a further child protection investigation, or a serious case review.
  • Liaise with other local authority services.
  • Provide feedback to social workers and other local authority staff involved in individual case management.

The role of the CDOP Chair

The Chair of the CDOP will be responsible for:

  • Chairing the CDOP meetings, encouraging all team members to participate appropriately.
  • Ensuring that all statutory requirements are met.
  • Maintaining a focus on preventative work.
  • Ensure that members are clear about their role, and facilitate resolution of inter-agency disputes.
  • Ensure that this process operates effectively.
  • Ensure that the annual report is completed and disseminated to each LSCB.

The role of the CDOP Coordinator

The CDOP Coordinator is responsible and accountable for the smooth running of all child death review processes:

  • Ensure and monitor the effective running of the notification, data collection and storage systems.
  • Identify and agree with key personnel of all agencies their engagement and responsibilities within the model.
  • Assist the LSCB in ensuring senior management in relevant agencies are aware of their roles and responsibilities in relation to Working Together to Safeguard Children, discussing any problems with the chair as they arise.
  • Facilitate the establishment of structures to support the CDOP as outlined in Working Together.

The CDOP will meet quarterly, throughout the year, drawing on comprehensive information from all agencies about the circumstances of each child death.

Terms of Reference will be reviewed and updated annually by the Child Death Overview Panel members.

Confidentially and information sharing

Information discussed at the CDOP meetings will not be anonymised prior to the meeting.  It is therefore essential that all members adhere to strict guidelines on confidentiality and information sharing. Information is being shared in the public interest for the purposes set out in Working Together and is bound by legislation on data protection.

CDOP members will be required to sign a confidently agreement before participating in the CDOP.  Any ad-hoc or co-opted members and observers will be required to sign the confidentiality agreement.  At each meeting of the CDOP, all participants will be required to sign an attendance sheet confirming that they have understood and signed the confidentiality agreement.

Any reports, minutes and recommendation arising from a CDOP meeting will be anonymised (where possible) and steps taken to ensure that no personal information can be identified.

Accountability and reporting arrangements

The Pan Berkshire CDOP is accountable to the Pan Berkshire Independent Chairs’ Group and the six individual LSCBs it represents.

The Child Death Overview Panel is responsible for developing its work plan, which should be approved by the LSCB Independent Chairs.  The Child Death Overview Panel will prepare an annual report for the LSCBs.  The report is responsible for publishing relevant, anonymised information.

The LSCBs take responsibility for disseminating the lessons to be learnt to all relevant organisations, ensuring that relevant findings inform the future LSCB Business plan, priorities, and sub-groups, and acting on any recommendation to improve policy, professional practice and inter-agency working to safeguard and promote the welfare of children.

  • The LSCB will supply data on child death information as required, e.g. National Clinical Outcome review programme initiative to collate and analyse information about child deaths across England, in order to identify lessons on the prevention of child death
  • Each year the Pan Berkshire CDOP Coordinator will provide evidence and a report on the CDOP LSCB statutory return form for each fiscal year.
  • A special Neonatal Strategic Group will meet once a year to look specifically for a deep dive for wider learning and will feed back to the Panel.

Conflict Resolution

The CDOP Chair should encourage panel members to form a consensus in their assessment and analysis of child deaths, if necessary by taking up issues outside the panel meeting.  However, where a consensus is not agreed, the Chair’s decision is final.

Members of the Pan Berkshire Child Death Overview Panel

  • Bracknell Forest Borough Council
  • West Berkshire Borough Council
  • Slough Borough Council
  • Wokingham Borough Council
  • Reading Borough Council
  • Windsor and Maidenhead Borough Council
  • Royal Berkshire NHS Foundation Trust
  • Berkshire Healthcare NHS Foundation Trust
  • Frimley Health NHS Foundation Trust
  • Berkshire West NHS Clinical Commissioning Groups
  • Berkshire East NHS Clinical Commissioning Groups
  • Thames Valley Police
  • South Central Ambulance Service
  • Daisy’s Dream Bereavement Charity


The CDOP is responsible for reviewing the deaths or all children and young people up to the age of 18 who are normally resident in Berkshire. Where a child dies in Berkshire but normally lives in another area, that death must be notified to the CDOP in the child’s area of residence. Similarly, when a child normally resident in Berkshire dies outside of this area, the Berkshire CDOP should be notified. In both cases, an agreement should be made as to which CDOP (normally that of the child’s area of residence) will review the child’s death and how they will report to the other.

There are two inter-related processes for reviewing child deaths:

  • Rapid response by a team of key professionals who come together for the purpose of enquiring into and evaluating each unexpected death of a child.
  • An overview of all child deaths in Berkshire, undertaken by CDOP.

The Berkshire Rapid Response Procedures and associate appendices:

explain the Rapid Response process in more detail.

Pan Berkshire Electronic Reporting mandatory for all child deaths from – 1st April 2019

Berkshire eCDOP is now live – from 1st April 2019 all notifications of a child death must be made via this link which anyone can access https://www.ecdop.co.uk/panberkshire/live/Public

For the rest of March Lorna Tunstall will accept notifications on paper Form A or through eCDOP but after 01/04/2019 notifications will only be accepted via eCDOP.

If you have any problems accessing please contact Lorna Tunstall, Pan Berkshire CDOP Coordinator lorna.tunstall@nhs.net, on 01753 875149 or 07850 209095

Pan Berkshire CDOP data

All CDOPs are required to make an annual return of data relating to child deaths to the Department for Education. Collated statistics from 2010 onwards are available on the Gov.uk website.

Pan Berkshire CDOP Newsletters are issued quarterly to share information and learning.

Here is the latest edition…

July 2019 Newsletter

Previous issues…









The 3rd Pan Berkshire CDOP Conference was held on Wednesday 24th of April 2019 at Reading University with 80 delegates from across Berkshire attending.  It was a multi-agency training event for professionals to raise awareness and develop new skills building on the learning from child deaths.

The key note speakers were Dr Sarah Hughes, Paediatric Consultant in Neurodisability, Dingley Child Development Centre and the Royal Berkshire Hospital, Reading; Superintendent Stan Gilmour, Local Police Area Commander, Reading and Detective Chief Inspector Christina Berenger, PVP (Protecting Vulnerable People) Berkshire, Thames Valley Police.

This year’s presenters focussed on the older child and young person; those living with complex health needs; neuro developmental disorders and acquired brain injury who may be vulnerable to exploitation and violence.

You can download the conference presentations here

Successful CDOP campaigns were shared with delegates around safe sleeping; improving the health, wellbeing and safety of young people at Reading Festival and raising awareness of Pneumococcal death and its prevention in ‘at risk’ groups.  Group work continued in the afternoon focussing on real cases.

New for this year was a marketplace of Exhibition Stands from the following organisations:

  • Police – CAIU (Child Abuse Investigation Unit)
  • eCDOP – QES
  • Alexander Devine – Hospice
  • Public Health/Immunisations
  • The Willow Project (Victims First) – Thames Valley Wide Exploitation & Complex Needs Service

Feedback from the training day was highly positive and will help strengthen the already successful CDOP in Berkshire and help further grow and develop the panel.  A full evaluation is attached. Download the Powerpoint here

Bereavement Support

Child Death Reviews

The death of a child is always tragic, and leaves families with a sense of shock, devastation and loss. If you have experienced the loss of a child in your family, then we understand that talking and thinking about this will be a sensitive and painful subject.

All child deaths must be reviewed by local Child Death Overview Panels. The main purpose is to improve support to bereaved families and to try and prevent future deaths. The Lullaby Trust has produced a booklet for parents and carers of any child that has died to explain the review process.

The loss of a child: The loss of a child is one of the most difficult things that can happen. If you are a parent or family member who has experienced the loss of a child then there is no right or wrong way for you to feel. People grieve in different ways and at different rates, and in some cases you might find that it is difficult to support each other through this sad and difficult time. There are a number of different organisations that can provide additional help and support, some of which are listed below.

The loss of a sibling: It can be difficult to know how to talk to children about the death of a sibling, for fear of upsetting them further. However, avoiding talking can leave children with further fears and anxieties. Being honest and including children as much as is possible (bearing in mind their age) is often helpful. For example children may want the opportunity to say goodbye to their sibling or to be involved with funeral plans. You should not be afraid to show your feelings to your children.

There are a number of helpful books, for children of all ages, which look at the loss of a sibling. Your local library or bookshop will be able to provide some advice if you want to choose a book that is suitable for your family. There are also a number of support services for children dealing with the loss of a sibling, some of which are listed below.

  • Daisy’s Dream supports children and their families who have been affected by the life threatening illness or bereavement of someone close to them.  Their Helpline is 0118 934 2604. Further information can also obtained be from their website: http://www.daisysdream.org.uk/

  • The Lullaby Trust provides information, support, guidance and signposting for bereaved families. They have produced a series of booklets that help explain the complex thoughts and feelings of grief, as well as the practicalities of an infant bereavement. Their Helpline staff can post these to you, or you can download them from their website Helpline: 0808 802 6868. Website: www.lullabytrust.org.uk/LThome

  • The Child Death Helpline: A free, confidential helpline for anyone affected by the death of a child. The helpline is staffed by volunteer parents who have also experienced the loss of a child. Helpline: 0800 282986 or 0808 800 6019 if calling from a mobile

  • BLISS: Provides support for parents of babies in Special or Intensive Care Units, as well as for bereaved parents. Helpline: 0500 618140 Website: www.bliss.org.uk

  • The Child Bereavement Charity: Provides specialised support, information and training to all those affected when a baby or child dies, or when a child is bereaved. Support and information line: 0800 02 888 40 Website www.childbereavement.org.uk

  • Childhood Bereavement Network: Provides information and signposting around child bereavement for parents, children and young people, families, and other caregivers. Website: www.childhoodbereavementnetwork.org.uk

  • Stillbirth and Neonatal Death Society (SANDS): Provides support for bereaved parents when their baby dies at, or soon after, birth. Helpline: 020 7436 5881 Website: www.uk-sands.org

  • Winston’s Wish: Offers practical support and guidance to families, professionals and anyone concerned about a grieving child, as well as telephone help and advice for bereaved children and siblings. Helpline: 0845 203 0405 Website: www.winstonswish.org.uk

Pan Berkshire CDOP prepares an annual report for the 6 LSCBs.  The report is responsible for publishing relevant, anonymised information.

CDOP Annual Report 2016-2017

CDOP Annual Report 2017-2018

About the New Arrangements

In October 2018 new guidance from Government titled ‘Child Death Review (CDR) Statutory and Operational Guidance’ has set out the key features of a good review process when a child dies, combining both statutory requirements and best practice. Berkshire child death review partners as directed by Working Together Transitional guidance has been required to publish their arrangements to meet the October 2018 guidance expectations.

Please find below the link to the Pan Berkshire response:

New CDOP Arrangements – June 2019