Child Death Review programme

There is a national requirement that all child deaths are reviewed, for which there are approximately 700 each year in London.

The Children and Social Work Act (2017) and subsequent statutory guidance outlined changes to the bodies responsible and the process of safeguarding children and reviewing child deaths which came into effect on 29 September, 2019. In May 2019, NHS England published a statement on the transition arrangements and in June 2019 they published guidance implementation FAQs to the Child Death Review section of the Future NHS Collaboration platform website.

Healthy London Partnership’s Child Death Review (CDR) programme supports London CCGs and local authorities (Child Death Review Partners) and specifically those involved in Child Death Review Meetings (CDRMs) and Child Death Overview Panels (CDOPs), to understand and comply with the new requirements, maximise their impact in the prevention of child deaths, and learn lessons to improve services for children and their families. The programme is funded by NHS England (London Region) until 31 March 2020.

Gathering feedback from bereaved families and carers

HLP in partnership with NHS England (London Region), Sands and a wide range of partners have developed a resource to support professionals collect data from bereaved families and carers following the death of a child or young person. This is available here. We hope that this tool will be useful in supporting the collection of such data and ultimately lead to an improvement in the quality of bereavement care.

Programme report, 2019

The Child Death Review (CDR) programme report outlining the activity and impact of the programme is available here.

Child death review e-learning programme

HLP is developing a free to access e-learning programme to support London professionals involved in or with an interest in, the child death review process, develop an understanding of the process, the statutory responsibilities, and best practice. This will shortly be available here. Once available, we encourage all professionals involved in the process to complete this modular course.

Pan-London access to eCDOP child death review case management system April 2018-March 2020

In 2018 NHS Digital funded pan-London access to the child death review online case management system, e-CDOP, developed by QES, for all London CDOPs until 31 March 2019. HLP facilitated the roll-out and adoption of eCDOP to the London CDOPs. Following feedback from child death review stakeholders across London, the public health commissioning team at NHS England (London Region) agreed to provide 12 months non-recurrent funding to support continued access to eCDOP for the London CDOPs. HLP will continue to manage the contractual arrangements with QES during this time.

All London CDOPs will therefore be able to continue to use eCDOP without charge between 1 April 2019 – 31 March 2020. However, from 1 April 2020, local CDRPs will need to fund any solution locally. There will be no further central (London) funding for eCDOP beyond this point.

Memorandum of Understanding with London Coroner

We have worked with HM Coroner for Inner South London Dr Andrew Harris, and colleagues from health and police across South East London to agree a single pathway to guide health professionals in the aftermath of managing the unexpected death of a child. This includes a memorandum of understanding from the Coroner’s officer pre-authorising certain processes after the death of a child; guidance for practitioners on statutory processes; and resources for bereavement support.

While it carries legal weight only within the Inner South London jurisdiction of Coroner Harris, we would encourage other areas to work with their stakeholders (coroners, police, hospital and community trusts, ambulance services) to use this as a template and develop and agree their own local versions in order to reduce the unnecessary variation in practice after a child’s death.

This work builds on the excellent South West London pathway which was agreed in 2018. We hope that other coronial jurisdictions will, if appropriate, agree local guidance along these lines.

Other useful information

HLP supported five London STP sector workshops between January -March 2019 to support child death review professions in London come together and discuss the challenges, considerations and potential solutions to meet the statutory requirements by September 2019. The Information pack and write up of the workshop outputs provides useful background information about the new statutory changes. HLP have also outlined the requirements of the different agencies involved in the child death review process.


If you have any queries about the CDR Programme, please email David McKinlay, Child Death Review Programme Manager.

The CDR Programme is led by Dr Ronny Cheung, Clinical Director, and Dr Donal O’Sullivan, Clinical Advisor.

Useful links

Related national programmes