Child Death Review

In England, it is a legal requirement for every child’s death to be reviewed by a Child Death Overview Panel (CDOP). 

These panels bring together senior representatives from health, social care and other relevant agencies.

The purpose is to :

• understand how and why children die, 
• to learn lessons from every death,
• and identify actions that can help protect others and prevent future tragedies. 

The panel reviews the deaths of all children under 18 who were normally resident in the area and, where appropriate, the deaths of non-resident children. This includes live-born babies of any gestation but excludes stillbirths, late foetal loss and legal terminations of pregnancy. 

The key functions of a CDOP are to: 

• Gather comprehensive information from all relevant agencies involved with the child and their family to develop a holistic understanding of the circumstances surrounding the child’s death.
• Determine any contributory factors and consider whether these could be modifiable. Modifiable factors are those where achievable national or local actions could reduce the risk of future child deaths.
• Identify learning and make recommendations to relevant organisations where actions have been identified that may prevent future child deaths or promote the health, safety and wellbeing of children.
• Produce an annual report on local patterns and trends in child deaths, lessons learned, actions taken, and the effectiveness of the wider child death review process.
• 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. 
• Submit data to the National Child Mortality Database (NCMD) to support a detailed national understanding of child mortality and ensure learning is widely shared.

The following reports and publications share some of the key findings and learning from child death reviews. 

Surrey CDOP :

Please see the SSCP Annual Report, which includes CDOP recommendations for learning and preventing child deaths in Surrey.

• 5 Year Thematic Review of Deaths by Suspected Suicide 2020 - 2025
• Sudden Unexpected Death in Infancy - A ten year review of deaths of babies normally resident in Surrey 2014 - 2024
• Safer Sleep Re-audit
• Four-year Report of patterns and trends Surrey Child Death Review 2018 - 2022
   

Sussex CDOP :

See below for our most recent annual reports:

• Pan-Sussex CDOP 2025-26 Annual Report  
• Pan-Sussex CDOP 2024-25 annual report
• Pan-Sussex CDOP 2023-24 annual report

Professionals who are involved in the immediate response following a child death are required to notify the relevant Child Death Overview Panel (CDOP) within 24 hours, or as soon as practicably possible.

Notifications should be made to the CDOP where the death has occurred. If you are a professional, please follow the links below and complete the relevant eCDOP notification form in full, providing all relevant and available information.

For deaths in Surrey:  Surrey CDOP

For deaths in Sussex: Sussex CDOP

 

Families going through the death of a child should be treated with empathy and compassion. They need clear, sensitive communication. They also need to understand what happened and know that lessons will be learned.

Professionals involved in any review or investigation should keep families informed throughout. Families should have chances to share their views, give information and ask questions. They should also be told the outcomes.

The booklet When a Child Dies: A Guide for Parents and Carers explains what may happen after a child dies and what support is available.

The family’s keyworker

Our Child Death Review (CDR) nurses make sure every family has a keyworker. A CDR nurse may act as the family's keyworker. If not, they will find another professional to take on the role.

The keyworker can:

• explain what happens during a child death review
• help families share their views and address any questions 
• help families access bereavement and specialist support services

For any family support enquiries, please contact the Child Death Review Nurse team.

Having their say

Families’ experiences and views are an important part of the review. They help professionals understand what happened, what went well and what could have been done differently.

For every child death, the professionals involved in the child’s care come together for a Child Death Review Meeting (CDRM). They look at the child’s care and what led up to their death. They aim to find out what happened and what can be learned.

• The meeting usually takes place within three months, unless more investigations are needed.
• For babies who die within 28 days of birth, the review usually uses the National Perinatal Mortality Review Tool (PMRT) process
• Families do not attend the meeting. They should be told when it is happening, and their keyworker can share their views, including any questions they want answered.
• The professionals agree who is best placed to give families feedback and answers afterwards.
• Learning from the meeting is shared with the Child Death Overview Panel (CDOP).

After the CDRM, the child’s death is also looked at by a Child Death Overview Panel (CDOP). Families are welcome to send anything they would like the panel to know. They can email:

Surrey CDOP: sysxicb.surreycdop@nhs.net

Sussex CDOP: sysxicb.sussexcdop@nhs.net

The panel looks at many deaths at each meeting. It does not re-examine or investigate individual cases. Instead, it looks for patterns and ways to improve services and help prevent future deaths. Anything that could identify children, families or professionals is removed first.

Because the CDOP considers child deaths collectively, it is not usually able to give families individual feedback.

Raising a concern or complaint

Families who are worried about any  review or investigation process should speak to their keyworker first. The keyworker will try to resolve and make sure the concerns are included in the child’s review.

If families feel their concerns have not been dealt with properly, or they are worried about how the CDOP works, they can make a formal complaint. 

Complaints should be written to the Chair of the CDOP at:

Surrey CDOP: sysxicb.surreycdop@nhs.net

Sussex CDOP: sysxicb.sussexcdop@nhs.net

Complaints are acknowledged within 3 working days. The Chair will tell the relevant Child Death Review Partners and aim to reply as quickly as possible, usually within 8 weeks.

When a child’s cause of death is not immediately clear, health professionals will work alongside the police and other agencies to understand how and why the child died and to ensure families receive the appropriate support. This coordinated approach is known as a Joint Agency Response (JAR).

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 sudden unexpected death in infancy/childhood (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.

A joint agency response should also be triggered if a child is taken to hospital near death, is successfully resuscitated, but is expected to die in the following days. In such circumstances, the JAR should be considered at the point of presentation and not at the moment of death, since this enables an accurate history of events to be taken and, if necessary, a ‘scene of collapse’ visit to occur. The purpose of this visit is to obtain further information about the circumstances and environment in which the child died, and to provide the family with information and support.

If a child is expected to die following an unexpected collapse, or has died unexpectedly, the Specialist Child Death Review Nurses should be contacted as soon as possible during working hours on 07917 212791. This will ensure that the JAR protocol is considered, triggered where appropriate, and that professionals are supported.

The “Sudden and Unexpected Death in Infancy and Childhood: multiagency guidelines for care and investigation (2016)” gives comprehensive advice and expectations of all agencies involved in a JAR, and should be applied in full by all agencies. Effective cross-agency working is key to the investigation of such deaths and to supporting the family. It requires all professionals to keep each other informed, to share relevant information between themselves, and to work collaboratively.

Professionals should also follow relevant local protocols across Surrey and Sussex. Please see further resources section for more information. 

Please find below a collection of key guidance and resources relating to the Child Death Review process.

• Sudden unexpected death in infancy and childhood: Multi-agency guidelines for care and investigation 

National Child Mortality Database (NCMD)

• Resources and guidance - relating to child mortality and the Child Death Review process
• Publications and analysis of child mortality in England 
• Introductory Joint Agency Response (JAR) training - for professionals who are new to responding to and reviewing sudden unexpected child deaths, including those who manage or support these processes.

Surrey:

• Surrey Child Death Review Policy July 2025 
• Surrey Child Death Review Team - FutureNHS Collaboration Platform 
• Suicide Prevention Toolkit
• Professional Leaflet Supporting Safer Bathing and Swimming for children with Epilepsy
• Parental Poster Supporting Safter Bathing and Swimming for Children with Epilepsy

Sussex:

• Sussex Child Death Review Practice Guidance - Sussex Child Protection and Safeguarding Procedures 
• Pan-Sussex CDOP Terms of Reference 2026-27