Learning from mistakes

Annex B: Observations on the Child Death Overview Panel Process

1. The Child Death Overview Panel has no investigative function. The purpose of the Child Death Overview Panel is to provide a mechanism for professional learning from incidents of child death. It is not intended to be a safety net to scrutinise individual cases and the evidence gathered. This is why it is anonymised.
2. The Child Death Overview Panel is a review and cannot be held responsible for the information it receives. The panel should be accountable for the effectiveness of its reviews but any organisation reporting to the panel is responsible for providing the most accurate information available. The Child Death Overview Panel is accountable to Ofsted as part of its reviews into local safeguarding and is the responsibility of the Department for Education, which also has a responsibility for children services.
3. The Child Death Review Meeting is a local case review, which reports to the Child Death Overview Panel and is not arranged or co-ordinated by the Child Death Overview Panel. It is part of the local overview process, and in this instance was arranged by the Trust hence it is included in this report.
4. Guidance issued for the Chair of a local case review states that a completed Form C should be supplied to the Child Death Overview Panel, together with summary notes of the meeting, and a completed recommendation sheet. The Chair should prepare a letter for those present, a proforma for the coroner, and most importantly a letter for the family.
5. The Chair should be independent and must not have been directly involved in a patients care. Working together to safeguard children (March 2015) recommends that where possible enquiries as part of the child death review process should not be led by the clinician who was responsible for the care of the child. This was not in place in the 2010 version but it is an understandable expectation.
6. Recent updates in policy and procedure have taken place in relation to the Child Death Overview Panel that deal with some of the issues that arise from events that occurred in 2011.
7. We note that a recommendation in the new guidelines is that the clinician responsible for the care of the child should not lead any subsequent investigations into that care. This is good practice and provides a good base for conducting the panel's business in an independent manner. However, we question whether the current guidelines go far enough in order to protect the integrity of the process. Were the guidelines to state that the Chair of the Panel MUST not have been involved in the case being reviewed, it seems to us that the impartiality of the process could less likely be questioned. We also note that in the new guidelines a recommendation has been included that families are invited to be involved in meetings as appropriate. We agree that family involvement is vital in such investigations wherever possible.