SAFEGUARDING CHILDREN BOARD
DONCASTER CHILD DEATH
REVIEW PROCESS
Terms of Reference
These terms of reference apply to the Child Death Overview Panel of Doncaster Safeguarding Children Board (DSCB) and its constituent agencies. The Doncaster Child Death Overview Panel (DCDOP) is a sub-committee of the DSCB, established in accordance with the Children Act (2004), the LSCB regulations (2006) and statutory guidance in Working Together to Safeguard Children (2013).
1. Purpose
1.1 The purpose of DCDOP is to collect and analyse information about each child’s death. One of the LSCB functions, set out in Regulation 6 of the Local Safeguarding Children Boards Regulations 2006, in relation to the deaths of any children normally resident in their area is as follows:
a) collecting and analysing information about each death with a view to identifying-
(i) any case giving rise to the need for a review mentioned in regulation 5(1)(e);
(ii) any matters of concern affecting the safety and welfare of children in the area of the authority; and
(iii) any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area, or
b) putting in place procedures for ensuring that there is a co-ordinated response by the authority, their Board partners and other relevant persons to an unexpected death.
1.2 DCDOP will review deaths of all children aged 0-18 (excluding both those babies who are stillborn and planned terminations of pregnancy carried out within the law) normally resident in the Local Authority area. Where DCDOP is made aware of the death of a child in their area who would normally be resident in another Local Authority area, or the death of a child in another area who would normally be resident in their area, the DSCB Support Team will liaise with the appropriate person in the other Local Authority area to ensure both Panels are notified of the death, and to determine which Panel is best placed to carry out a review of that child’s death.
2. Functions
2.1 The functions of the DCDOP include:
i. implementing this protocol and supporting the implementation of the DCDRRT protocol. These are both in accordance with guidance issued in ‘Working Together to Safeguard Children’ 2013 on enquiring into unexpected deaths, and evaluating data concerning all deaths in childhood in Doncaster[1]. This should take place in consultation with the Doncaster Coroner’s office;
ii. collating an agreed minimum data set and, where relevant, seeking other information from key professionals.
iii. Involving parents/carers and other family members in both the child death overview and rapid response processes, informing of the date of the review and supporting them to contribute if they wish.
iv. meet frequently to evaluate the data on the deaths of all children, enabling identification of lessons to be learnt or issues of concern. This should have a particular focus on effective inter-agency working to safeguard and promote the welfare of children;
v. consider findings presented within DCDOP related to equalities issues, specifically regarding gender, ethnicity, disability and sexuality;
vi. provide a mechanism to review specific child deaths in detail when necessary at DCDOP meetings;
vii. monitor the appropriateness of the response of professionals to an unexpected death of a child. This will include reviewing reports received by the DCDRRT concerning each child, recording such discussions and providing professionals with feedback about their involvement. Where there is an ongoing criminal investigation, the Crown Prosecution Service should be consulted as to what is appropriate for the DCDOP to consider and what actions it can take without prejudicing any criminal proceedings. Reference should also be made to the Doncaster Serious Case Review Protocol and liaison should take place between the Chair of DCDOP and the Chair of DSCB on issues relating to abuse and neglect;
viii. the Chair of DCDOP should refer to the Coroner and Chair of DSCB any deaths of concern, where DCDOP believes that there are grounds for further enquiries or investigations and the case does not relate to abuse or neglect. The DCDOP Chair should make specific representation to agencies in order to gather required information;
ix. the Chair of DCDOP should refer to the Chair of DSCB and the Coroner any deaths of concern, where DCDOP believes that there are grounds for further investigations or a Serious Case Review and explore why this had not been recognised previously.
x. inform the Chair of DSCB where specific new information should be passed to the Coroner or other appropriate authorities;
xi. provide relevant information to those professionals involved with the child’s family so that they can convey the information to them in a timely and sensitive manner;
xii. provide written information for families about the role of DCDOP;
xiii. publish an annual DCDOP report;
xiv. monitor the support and assessment services offered to families of children who have died;
xv. monitor and advise DSCB on the resources and training required locally to ensure an effective inter-agency response to child deaths. For example, additional questions within the data collection process to assess time taken to collate and complete the data set required for each professional
xvi. organise and monitor the collection of data for the nationally agreed minimum data set, and make recommendations for any additional information to be collected locally, both in Doncaster and in South Yorkshire as appropriate;
xvii. identify any public health issues and consider, in consultation with the Director of Public Health, how best to address these and the implications for both service provision and training;
xviii. co-operate with relevant regional and national initiatives to identify lessons on the prevention of unexpected child deaths;
xix. liaising with media as necessary. The annual report will be a public document, which is likely to generate interest. A planned press release may be effective in handling media enquiries, written by the DCDOP Chair in conjunction with the DSCB Chair.
3. Accountability
3.1 DCDOP will be responsible, through its chair, to the Chair of DSCB. The Panel will provide to DSCB and all constituent agencies, an annual report (in which all information should be aggregated and anonymised) which shall be a public document. In addition, the Panel will report to DSCB any matters of concern arising from the course of its work as set out above.
3.2 DSCB will take responsibility for disseminating the lessons to be learnt to all relevant organisations; ensuring that relevant findings inform the Children and Young People’s plan; and acting on any recommendations to improve policy, professional practice and inter-agency working to safeguard and promote the welfare of children.
3.3 DSCB will supply data regularly on every child death, as required by the Department for Education, to bodies commissioned by the Department to undertake and publish nationally comparable, anonymised analyses of these deaths.
3.4 The DCDOP Chair will report the recommendations and lessons learned arising from child death reviews to the Serious Cases Panel for notification and progression.
3.5 The DCDOP Chair will be invited to attend the Serious Cases Panel by exception to report on the DCDOP recommendations and lessons learned.
4. Administration
4.1 DCDOP will be chaired by the Chair of DSCB or his/her representative. The work of the Panel will be co-ordinated by the DSCB Support Team.
5. Membership
5.1 DCDOP will have:
· a fixed core membership drawn from key organisations represented on the DSCB
· the flexibility to co-opt other professionals to become panel members on a case by case basis
5.2 Core members:
· Chair (Member of DSCB)
· Coroner’s Office
· Public Health
· South Yorkshire Police
· Doncaster and Bassetlaw Hospital Foundation Trust - Panel Paediatrician
· Doncaster and Bassetlaw Hospital Foundation Trust – Rapid Response Specialist Nurse
· Midwifery
· DMBC Children’s Social Care
· Doncaster Clinical Commissioning Group (CCG) – Designated Nurse (Child Protection/ Safeguarding Team)
· Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH)
· Lay member
5.3 Co-opted members:
· Representative from one of the Health Providers or Commissioners
· Designated Doctor (Safeguarding Children)
· Doncaster Metropolitan Borough Council Services[2]
· Children and Family Court Advisory and Support Service (CAFCASS)
· Education Professionals
· Probation Service
· South Yorkshire Fire and Rescue Service
· Yorkshire Ambulance Service
· Safer Doncaster Partnership
· NSPCC
· British Transport Police
· Any other agency as required including statutory agencies and the voluntary/community sector.
5.4 Agencies listed above should agree who is the most appropriate member of staff to represent them on DCDOP. They should also agree a designate. When it is not possible for the agreed representative to attend, the designate should attend on their behalf. The Coroner will be sent minutes of DCDOP.
5.5 Attendance of agencies at DCDOP meetings will be monitored, as occurs with DSCB members. If there is concern about the attendance of particular agencies, the Chair will make representation to that agency at Chief Executive level, in order to resolve the issue.
5.6 South Yorkshire Police, DMBC Social Care and Health should be represented at every meeting.
6. Confidentiality and Information Sharing
6.1 Information discussed at DCDOP meetings will be anonymised prior to Panel meetings. It is 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.
6.2 At each DCDOP meeting, members in attendance will sign a confidentiality agreement. This will also be used as the attendance register. It is particularly important for members to sign each time, as attendance will vary depending on which co-opted members attend.
6.3 Any reports, minutes and recommendations arising from DCDOP will be fully anonymised and steps taken to ensure that no personal information can be identified.
7. Child Protection Concerns
7.1 Where there is an ongoing criminal investigation, the Crown Prosecution Service must be consulted as to what it is appropriate for the Panel to consider and what actions it might take in order not to prejudice any criminal proceedings.
7.2 If, during the enquiries, concerns are expressed in relation to the needs of surviving children in the family, discussions should take place with LA children’s social care. It may be decided that it is appropriate to initiate an initial assessment using the Framework for the Assessment of Children in Need and their Families (2000).
7.3 If concerns are raised at any stage about the possibility of surviving children in the household being abused or neglected, the inter-agency procedures set out in Chapter 1 of Working Together should be followed. The police and Coroner must be informed immediately that there is a suspicion of a crime or evidence comes to light that the death may be of a suspicious nature. The Chair of DSCB should be informed of the case to ensure that appropriate procedures are followed and to consider the need for a Serious Case Review.
8. Partner Agency Responsibilities
8.1 Each partner agency of DSCB will identify a senior person within their organisation who has responsibility for representing the agency on DCDOP. Each agency will ensure their representative is allocated sufficient time in their job plan to attend all Panel meetings, having prepared in advance of the meetings, and is able to report back to the agency any specific recommendations arising from the panel.
8.2 Partner agencies will ensure that staff in their agency who become aware of the death of a child will report that child’s death to the Panel. Partner agencies will ensure that relevant staff are made aware of the child death review functions of DSCB and are able to access appropriate training.
9. Working with the media
9.1 Media interest in the work of DCDOP or in individual cases will be dealt with by the DCDOP Chair in conjunction with the DSCB Chair. As previously stated the annual report of DCDOP will be a public document and as such will contain no identifiable information. Details of individual case discussions are to be kept confidential and in no circumstances will such details be passed to the press. The Chair of DSCB and DSCB Support Team will work proactively with the media to promote the work of DCDOP alongside that of DSCB in safeguarding and promoting the welfare of children in the area.
15th July 2010
Updated 19th January 2011
Updated 29th June 2011
Updated August 2013
Appendix A
Information Flow between the Child Death Overview Panel (CDOP) and the Serious Cases Panel
· CDOP meet on a quarterly basis to review all deaths of children who normally reside in Doncaster and are aged between 0-18 (excluding both those babies who are stillborn and planned terminations of pregnancy carried out within the law).
· Recommendations made by CDOP arising from child death reviews will be documented within case files and minutes of panel meetings. The CDOP Chair is responsible for sharing this information with the Chair and members of the Serious Cases Panel.
· The CDOP Chair will attend the relevant Serious Cases Panel and present information about the specific recommendation.
· The Serious Cases Panel will be asked to consider and direct any further action that is required in relation to the recommendation.
· Recommendations from CDOP will be structured using the previously defined national dataset recommendation categories as set out below:
· Recommendations specific to the management of an individual case
· Training commissioners/providers
· Changing local organisational structures and practices
· Changing regional organisational structures or practices
· Influencing legislation or national policy
· Community education/awareness
· National education/awareness
· Advocacy and health promotion
· Mobilising local communities
· Other recommendations
· Unknown recommendations
The CDOP Annual Report will only record the recommendation by national category.
· Serious Cases Panel decisions in relation to the recommendation will be shared with CDOP members at the most appropriate panel meeting.
· The Serious Cases Panel will be responsible for monitoring the progress/outcomes of the recommendation and inform the CDOP members.
7
With effect from 11.11.11
Updated in line with WT 2013 September 2013
[1] DCDOP will usually review Doncaster children who die elsewhere.
[2] For example Legal Advisor and Road Safety.