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Safeguarding: Serious Case Reviews

Updated on Tuesday, 22 January 2019, 616 views


Since 1st April 2008 Child Death Review (CDR) processes have been mandatory for Local Safeguarding Children Boards (LSCBs) in England.

CDR includes two interrelated processes that may trigger a serious case review:

review of all deaths under the age of 18  by the local Child Death Overview Panel led by a designated paediatrician and including healthcare professionals, police and social workers. The panel is accountable to the Chair of the LSCB.

rapid response by key professionals coming together to enquire into and evaluate every unexpected death of a child. 


A Child Death or Serious Case review (CDR) includes two interrelated processes that may trigger a serious case review:

review of all deaths under the age of 18  by the local Child Death Overview Panel led by a designated paediatrician and including healthcare professionals, police and social workers. The panel is accountable to the Chair of the LSCB.

rapid response by key professionals coming together to enquire into and evaluate every unexpected death of a child. 

Aims of the CDR Process:

to document and understand the cause of death so parents can come to terms with the death and take steps to prevent the deaths of any other children.

to identify patterns of deaths in a community so preventable or avoidable hazards can be recognised and reduced.

to contribute to improved collection of forensic evidence where there might be concerns of maltreatment or other criminal act.

GPs and other members of the primary healthcare team have key roles in the identification and protection of children at risk, and now have a vital role in the CDR processes.

Concerns about confidentiality are often raised, but it is absolutely clear that the safety of children is paramount.  A GP is permitted to breach confidentiality in order to prevent death or serious harm, to facilitate the investigation of a possible crime or to pursue the due legal process.  A GP is also obliged to cooperate with a Coroner’s enquiry,

The aims of the CDR processes are clearly aligned with the protection of all children and the appropriate investigation of all child deaths. 

Working Together specifies that each PCT should have access to a “designated paediatrician for unexpected deaths in childhood”, who can provide advice and training to other health professionals and to the PCT and also contribute to the Child Death Overview Panel.

In addition each PCT has a Child Protection Lead who may be contacted for advice.

Response to the Unexpected Death of a Child:

When the unexpected death of a child occurs, if the GP confirms the fact of death the coroner and the designated paediatrician must both be contacted.

Normally the body would be taken to the A&E department unless the police are involved and require that the body is not moved.

The initial response of the Rapid Response Team may include a home visit within 48 hours and the gathering of information from the child’s GP/HV/school nurse or any other relevant individual.

The child’s GP will be asked to complete a form and return this to the Child Death Overview Panel (CDOP).

Once the designated paediatrician receives the post-mortem results, a multi-agency discussion would be convened, probably by telephone.

Subsequently a further case discussion meeting would include those who knew the child and family, as well as those who have investigated the death, in order to share information, identify the cause of death and consider factors that may have contributed to the death.

The Child Death Overview Panel will review the appropriateness of the professionals’ responses to each unexpected death of a child, their involvement before the death, and relevant environmental, social, health and cultural aspects of each death, to ensure a thorough consideration of how such deaths might be prevented or avoided in the future.

The child’s GP is expected to attend the discussion and may be asked to contribute to a written report.  The venue for the meeting is likely to be close to the child’s family, such as the GP’s surgery. 

The future care of the family would form part of this discussion and any potential lessons for the future would be identified.

There should generally be an explicit discussion of the possibility of abuse or neglect either causing or contributing to the death.

Finally, the team leader would discuss the results of the post-mortem with the parents of the deceased child, usually in the presence of a member of the primary healthcare team.

Each Panel will co-operate with regional and national initiatives (eg the Confidential Enquiry into Maternal and Child Health) to identify lessons on the prevention of unexpected child deaths.

BMA Child Death Review Process-GP Responsibilities


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