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Child Death

The death of a child is a devastating loss that profoundly affects all of those involved. It is important for parents, families and practitioners to understand what has happened and whether there are any lessons to be learnt.

Child Death Overview Panel (CDOP)

Child deaths are tragic, and thankfully uncommon, and it is important that we take the opportunity to learn from these devastating events. Comprehensive reviews of child deaths undertaken by the Child Death Overview Panel (CDOP) serve an invaluable public health function. They investigate what happened and why and identify common trends or themes to help inform and improve the quality of health and social care. This in turn links to multi agency child safeguarding and promotes child welfare, ultimately with the aim of preventing future child deaths.
The CDOPs were historically managed under the four Local Children’s Safeguarding Partnerships (LCSPs) and they now work together under one CDOP covering all of Hampshire, Isle of Wight, Portsmouth and Southampton, the HIPS CDOP.  This is an equal partnership for the mutual benefit of all children and young people involved and provides an oversight and assurance of the whole Child Death Review (CDR) processes in accordance with the National Child Death Review Statutory and Operational Guidance 2018 and Local CDR policies.


The Hampshire, Isle of Wight, Portsmouth and Southampton (HIPS) Child Death Overview Panel (CDOP) has the single statutory duty to report every child death to the National Child Mortality Database (NCMD) immediately after death.

The Child Death Review (CDR) is the process then followed when responding to, investigating, and reviewing the death of any child under the age of 18, as defined in the Children Act 2004 from any cause. A CDR must be carried out for all children regardless of the cause of death. This includes the death of any live-born baby where a death certificate has been issued. It runs from the moment of a child’s death to the completion of the review by the CDOP.

The process is designed to capture the expertise and thoughts of all individuals who have interacted with the case in order to share information and identify opportunities to save the lives of children, as set out in the Child Death Review Statutory and Operational Guidance 2018 and in accordance with Working Together to Safeguard Children 2018 .


The HIPS Local Authorities and Clinical Commissioning Groups are the CDR Partners and the CDOP has representation from:

  • Designed Doctor for Child Deaths/Consultant Paediatrician
  • Public Health
  • Police
  • Consultant Neonatologist
  • Consultant Obstetrician
  • Designated Nurse for Safeguarding
  • Midwifery
  • Children’s Social Care
  • Children’s Education
  • Lay Member

The Panel members are all senior professionals who bring significant expertise from a wide range of perspectives and settings for objective, comprehensive and meaningful reviews.

In addition to the core membership, relevant experts from health and other agencies are invited as necessary to inform discussions, for example, the Regional Medical Examiner, Bereavement Services, Health Visiting, Mental Health Services, School Nursing and Coroner’s Office.

Child Death Notification and Reporting

All child deaths are to be notified to the HIPS CDOP Team via the eCDOP online nationally approved system at https://www.ecdop.co.uk/HIPS/Live/public  and this will automatically update the National Child Mortality Database.

Reporting forms for each child death will be requested via eCDOP and this will be managed by the HIPS CDOP Team.

Examples of the information that is to be shared via the secure online system can be seen in the following documents:

Joint Agency Response

Consideration of a Joint Agency Response (JAR) should occur each time a child dies and a joint decision should be taken as to whether it is required.  The new guidance no longer distinguishes deaths in terms of unexpected or expected.  A Joint Agency Response should be triggered if a child’s death:

  • is or could be due to external causes;
  • is sudden and there is no immediately apparent cause (including SUDI/C);
  • occurs in custody, or where the child was detained under the Mental Health Act;
  • where the initial circumstances raise any suspicions that the death may not have been natural; or
  • in the case of a stillbirth where no healthcare professional was in attendance.

Bereavement Support

It is vital every family receives bereavement support. further information is available here.


The HIPS CDOP has produced an Annual Report and a Bi-Annual Report detailing any recommendations and learning. The report is a public document and does not contain information that could identify an individual child or their family:

Suicide Prevention and Postvention Protocol for IOW Schools and Colleges

This protocol has been developed to help schools and colleges on the Isle of Wight identify and support students who may be suicidal and importantly to consider a wide range of associated issues, in the case of a death by (suspected) suicide. It both supports schools/colleges to prepare in case there ever is a (suspected) suicide, and also how to best respond when a suspected suicide has taken place. The protocol can be accessed on the Isle of Wight Council website here.