Report a child death

Losing a child is tragic. Talking and thinking about a child’s death is a sensitive subject. It is important that we respond with care and support for families, carers, and professionals.

Any agency or professional should make a notification of a child death if:

a child death has occurred in Cumbria
a death of a child, normally resident in Cumbria, occurred elsewhere

You can report the death using the online notification form.

To make sure the forms go to the right person, please also send the name and email of that person to cdop@cumbria.gov.uk.

Once submitted, the notification form will be processed by the CDOP Co-ordinator.

Reviewing of child deaths

All local safeguarding partnerships in England are required to review child deaths. This is to help us understand how a child has died, put in place interventions to protect other children and try to prevent future deaths wherever possible.

These reviews aim to:

help families understand the cause of death
identify ways to prevent similar deaths
identify any patterns or risks in the community to prevent future harm
improve how we gather information if there are any safeguarding concerns
help improve evidence gathering in rare cases where the death may have been non-accidental
improve how services work together to share learning and safeguard children

Useful documents

Further help

If you’re a professional with a question about a child’s death, please contact:

Sharon Mitchell
Child Death and CSCP Case Review Coordinator
Telephone: 07795 047 888
Email: cdop@cumbria.gov.uk

Child death review process

How the process works, how agencies work together and how families are involved.

Purpose of the review

The Child Death Review process gathers information about all child deaths in the area. The aim is to understand the cause of death, identify any contributing factors and learn lessons that may help prevent future deaths.

Key outcomes include:

making recommendations to improve child health, safety and wellbeing
contributing to local, regional and national learning
supporting improvements in services through shared learning

Child Death Overview Panel (CDOP)

CDOP is a multi-agency group that reviews every child death (under 18) in Cumbria. It is chaired by an independent professional and includes representatives from:

Local Authority Children’s Services and Education
health professionals (paediatrics, midwifery, GPs, nursing)
Police
other experts as needed

The Panel meets every two months. All information is anonymised, confidential, and treated with care and respect.

Involving families

Following a child’s death, parents receive a letter and an NHS England booklet explaining the review process and how they can share their thoughts or experiences, if they wish.

Reporting and learning

CDOP submits an annual report to the Cumbria Safeguarding Children Partnership Board and Lead Safeguarding Partners (LSPs). Reports are public but do not include any personal details.

The Panel also gathers sensitive, confidential information to support the review. This work follows the legal framework set out in Working Together to Safeguard Children (2018), Chapter 5.

Unexpected death

Working Together to Safeguard Children 2018, Chapter 5 defines the unexpected death of a child which was not anticipated as a significant possibility 24 hours before the death, or where there was a similarly unexpected collapse leading to or precipitating the events that led to the death.

Joint agency response (JAR)

It is the responsibility of the Local Authority and the Integrated Care Boards to ensure that the Child Death Overview Panel (CDOP) conducts a review of each death of a child who was normally resident in their area.

Purpose of the joint agency response

The JAR process ensures a swift, coordinated response to any unexpected child death. Agencies work together to:

respond promptly and investigate the circumstances
promptly investigate and assess the causes and circumstances of the death, in coordination with the coroner
carry out enquiries related to each organisation's current responsibilities and actions when a child dies unexpectedly. This includes working with those supporting the rest of the family
collect data using nationally agreed standards
a lead professional is assigned to stay in contact with the family and ensure they are supported and informed throughout the process

Timeline of the response

Phase 1 – immediate response

Takes place within the first few hours, involving hospital staff, police and the coroner.

Phase 2 – JAR meeting (within 72 hours)

A multi-agency meeting is held, including professionals such as paediatricians, police officers, GPs, health visitors, midwives, and social workers, working in accordance with the guidance within Working Together to Safeguard Children 2018.

Phase 3 – Child death review meeting

Held after post-mortem results (if applicable) and before any inquest. All involved professionals come together to share findings.

Final review by CDOP

After the inquest (if required), CDOP reviews the full case to:

classify the cause of death
identify modifiable factors
make any recommendations for change and who they should be addressed by

This local process follows Cumbria’s CDOP procedures and national guidance.