Child Death Review Report : Scottish Government Child Death Review Working Group

A report by a Scottish Government short-life working group which explored current practice in Scotland and considered whether Scotland should introduce a national collaborative multi-agency system for reviewing the circumstances surrounding the death of a child.

Child death review systems: Evidence from other countries


26. There are 148 Local Safeguarding Children Boards in England and 93 Child Death Review Overview Panels (CDOPs). From 200816 CDOPs have had statutory responsibility for the provision of 'Rapid Response Teams' and 'Child Death Overview Panels' were organised on a local authority basis with input from appropriate clinical staff from health. Local teams operate under the auspices of Child Safeguarding which is usually local authority led (and is similar to Scotland's Child Protection Committees).

27. A recent review of all CDOPs in England can be found at: This report makes several recommendations to improve child death review data collection and structure/process.

Recommendations from English child death review report (2013)17

  • CDOPs must continue to be locally based and to have a local focus in order to continue their work with local services and agencies to ensure both the provision of data needed for the CDOP process and to ensure that recommendations for service improvements are locally relevant and acted upon locally.
  • A national database should be established to enable the collection, analysis, interpretation and reporting of CDOP data at a national level.
  • The database and the associated standardised data collection tools required to ensure high quality data are collected must be designed in collaboration with CDOP staff to ensure that they meet the CDOP data needs and local analysis requirements whilst a sub-set of the data is made available for national analysis.
  • The database should be commissioned from a provider who is experienced in national data collection and analysis and has the requisite clinical skills to interpret the findings and to issue appropriate alerts and alarms when necessary as well as producing an annual national report.
  • Links must be established with other national data collections and child health intelligence networks to ensure maximum benefit is derived from the data collected and the recommendations made.
  • The continuation in some places and re-establishment in others of regional meetings is essential to ensure shared learning across CDOPs continues. Funded national meetings would also support one element of shared national learning and the goal of making better use of child death review data. Such meetings could be stand alone or form part of the remit of a national database provider.


28. A similar process for Child Death Reviews has been established in Wales.

Northern Ireland

29. Northern Ireland has a review process and a safeguarding board. Models for a child death review process are being studied in Northern Ireland with a view to implementing a national system.

Other countries

30. The USA, Canada and New Zealand in particular have well established Child Death Review Systems. There is now considerable experience in these other high income countries who have shown that a process of reviewing all child deaths in the population can both identify preventable deaths and reduce mortality rates in certain populations. For example, data collated across the USA has resulted in changes in state law on swimming pool design, on road junctions, identified areas where child protection systems are functioning inadequately, resulted in enhanced 'Back to Sleep' advertising campaigns. This has evidenced reductions in maltreatment deaths due to better targeting of resources and the development of better mechanisms for the identification of children at risk. The US system has been of particular interest to other nations seeking to develop child death review processes because of its simple and inexpensive process18 The National Centre for Child Death Review Policy and Practice ( has provided a rich source of detailed data that can be used to direct public health policy for children.

31. There is now a credible body of literature going back ten years affirming the efficacy of reviewing all child deaths in a process which collects and collates standard data and translates that data and recommendations into local and national policy initiatives.19,20,21,22.


Email: Mary Sloan

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