About the Programme
This section explains the history of the National Child Mortality Database project and provides access to further relevant resources.
The Evolution of the National Child Mortality Database
The child death review process in England began on 1 April 2008. This was the result of two high profile miscarriages of justice which led to the convictions, and subsequent exonerations of Angela Cannings and Sally Clark. Professor Peter Fleming was the paediatrician whose work on investigating the deaths of children who die suddenly and unexpectedly (sometimes referred to as “cot death”) played a key role in securing the exonerations of these two mothers who had been wrongly convicted of killing their children.
Professor Fleming identified that in both of these cases, and others, all of the information needed to explain what had happened was obtained within three months of the deaths of their children, but it needed a multi-agency perspective to understand the significance of the information held. Following this it was identified that there was a need to review the deaths of all children to identify what can be learned, to improve the lives of young people and their families and to ensure that no further miscarriages of justice occurred.
Setting up the process
When the process was first set up, the responsibility for delivering it was given to the Local Safeguarding Children Boards (LSCBs) and the government department who held overall responsibility for the process was the Department of Children Schools and Families (DCSF) .
LSCBs are responsible for improving the overall wellbeing of children in their local authority
area and each board has a statutory duty to review the deaths of all children normally resident in their area, who die before their 18th birthday.
Areas with a population of 500,000 or more were required to set up a Child Death Overview Panel (CDOP) and to implement a process for the investigation of children who died suddenly and unexpectedly, known as a rapid response.
Statutory guidance for the process was set out in a document called Working Together to Safeguard Children and a set of statutory forms were produced to assist LSCBs with data collection and to give CDOPs as much information as possible to review each death.
Department for Education takes responsibility for CDOP
The next milestone for the process came in 2010 when the Department of Children Schools and Families (DCSF) was replaced by the Department for Education (DfE) and the CDOP process then became the responsibility of that department.
At this time, the statutory forms were also reviewed and updated, and a set of supplementary forms were introduced, designed to ask more detailed questions depending on the cause of death. These were implemented, and local CDOPs began to develop their own amendments to these forms to suit the needs of their individual panels.
Identification of challenges faced by CDOPs
The process remained largely unchanged until the beginning of the review into the role and function of LSCBs conducted by Alan Wood MP in 2016.
Alan Wood’s review identified a number of challenges with the way CDOPs worked and the organisation of the process and made a number of recommendations.
These included a change in the government department sponsoring the process from the Department for Education to the Department of Health, the recognition of the need for child deaths to be reviewed over a population size that gives a sufficient number of deaths to be analysed for patterns, themes and trends and the implementation of a national database to collate information gathered by CDOPs
Moving towards Child Death Reviews Statutory and Operational Guidance
Following the publication of Alan Wood’s recommendations, the government held a consultation between October and December 2017 to seek views on revisions to Working Together to Safeguard Children.
The consultation asked a number of questions related to the child death review process and the work of CDOPs. The conclusions were then published along with the government’s response to the consultation in February 2018. Work then began on the revised version of Working Together to Safeguard Children which was published in July 2018.
This version made reference to a new document, Child Death Reviews Statutory and Operational
Guidance, which was published in October 2018. This document provides a huge level of detail for those commissioning and delivering child death review processes and aims to reduce some of the variability of practice that had developed between CDOPs over the years to enable a more consistent approach to the review of child deaths.
Updates were also made to the statutory forms, new versions of which were published in September 2018
Child Death Review Database Development Project Report
Alongside the above, in July 2016, the report of the Child Death Review Database Development Project was published. This project was commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England and the Health and Social Care division of the Scottish Government.
The purpose was to investigate whether and how it might be possible to create a national database of information collected in the course of child death reviews conducted by CDOPs in England and the CDRPs, which were recommended in Scotland during the course of the development project.
The findings of this project demonstrated overwhelming support for the creation of a national child death
review database both from parents and professional stakeholders.
In February 2018 a National Child Mortality Database was commissioned by HQIP on behalf of NHS England.
The purpose of the database was to collate data collected by CDOPs at a national level and by analysis of this data to reduce preventable child mortality in England.
Following the conclusion of a procurement process, a contract was awarded to a collaboration led by the University of Bristol and involving University of Oxford’s National Perinatal Epidemiology Unit, UCL Partners and QES.