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I) Child Death

Overview of Child Death

Notification of child death

Are you aware of a child death and want to notify the Child Death Overview Panel

The way child deaths are notified to the Child Death Overview Panel has changed. 

We are now using an electronic management system called 'eCDOP''

Previously, you may have been asked to download a 'CDOP Form A - Notification of Death' fill in the relevant sections and email to the CDOP Co-ordinator.  This system has been replaced.

Now, if you would like to submit a notification go directly to the following link: https://www.ecdop/

Simply input the details and press the green submit button.  This system is completely secure and the notification of death you have submitted will go directly to the CDOP Co-ordinator to generate a case.

This link is for notifications of death for children resident in Staffordshire and Stoke-on-Trent.

Staffordshire and Stoke-on-Trent LSCB  follows the statutory requirement for all Local Safeguarding Children Boards (LSCB) to ensure that a review of each death of a child normally resident in the LSCB’s area is undertaken.

Staffordshire and Stoke-on-Trent LSCB's share one panel. The Panel has a fixed core membership drawn from organisations represented on the LSCB and have flexibility to co-opt other relevant professionals to discuss certain types of death as and when appropriate. The Staffordshire and Stoke-on-Trent CDOP has a professional from public health as well as child health.

Core Panel Members: October 2019

  • Nicki Furlong Chair DCI Staffordshire Police
  • Paula Carr Deputy Chair Designated Nurse for Child Protection, Stoke-on-Trent Clinical Commissioning Group
  • Faith Lindley-Cooke Child Death Co-Ordinator
  • Azhar Manzoor Designated Doctor for Unexpected Death, South Staffordshire
  • Martin Samuels Designated Doctor for Unexpected Death, North Staffordshire & Stoke-on-Trent
  • Alex Tabor Designated Doctor for Unexpected Death, North Staffordshire & Stoke-on-Trent
  • Simon Caton Detective Inspector, Staffordshire Police
  • Rebecca Sage Child Death Nurse Practitioner, South Staffordshire (role currently covered by Caroline Dodd)
  • Gill Devine-Skellern is Child Death Nurse Practitioner, North Staffordshire & Stoke-on-Trent
  • Lynne Milligan Interim Staffordshire Safeguarding Children Board Manager
  • Angela Jervis Head of Safeguarding, Staffordshire & Stoke-on-Trent Partnership NHS Trust
  • Stephanie Nightingale - Designated Nurse for Safeguarding and Looked After Children South East Staffordshire & Seisdon Peninsula Clinical Commissioning Group
  • Andrea Muirhead Children and Young People Public Health Lead, Stoke on Trent Directorate : Public Health
  • Kate Sutcliffe Commissioning Officer for Children and Families Health and Wellbeing, Staffordshire County Council
  • Claire Cartwright - Business Manager Safeguarding and Review

The Child Death Overview Panel should be informed of the deaths of all children normally resident in their geographical area. The Designated person to whom the death notification and other data on each death should be sent is the CDOP Co-ordinator. The Co-ordinator also uses sources available, such as professional contacts or the media, to find out about cases when a child who is normally resident in their area dies abroad.

In cases where organisation in more than one LSCB area have known about or have had contact with the child, lead responsibility should sit with the LSCB for the area in which the child was normally resident at the time of death. Other LSCBs or local organisations which have had involvement in the case should cooperate in jointly planning and undertaking the child death review. In the case of a looked after child, the LSCB for the area of the local authority looking after the child should exercise lead responsibility for conducting the child death review, involving other LSCBs with an interest or whose lead agencies have had involvement as appropriate.

Information relating to all children under the age of 18 is collected using the data set agreed with the Department of Education (Form B - please see Notification data).
Following review, all actions and recommendations will be tracked and reported back on in the CDOP action sheet following each meeting. The work of the Child Death Overview Panel is summarised in an annual report.   More information about the child death review process can be found within Working Together to Safeguard Children 2018

Child Death Overview Panel Co-ordinator For Staffordshire and Stoke-on-Trent this is Faith Lindley-Cooke.
Tel: 101 ext : 2724, Email:

Designated Doctor for Unexpected Death (DDUD)
Within Staffordshire and Stoke-on-Trent there are 3 Designated Doctor’s for Unexpected Death and 2 Child Death Overview Panel Nurse Practitioners. They have expertise in undertaking enquiries into unexpected deaths in childhood. 

DDUD for South Staffordshire

Dr Azhar Manzoor,  
Consultant Paediatrician, Queen's Hospital, Belvedere Road,
Burton-on-Trent, DE13 ORB

Office Telephone:

Mobile Telephone:

01283 511 511 ext 4360

 07951 924 576

DDUD for North Staffordshire

Dr Martin Samuels, Consultant Paediatrician, Academic Department of Paediatrics, 
Royal Stoke, University Hospital of North Staffordshire NHS Trust,  1st Floor Admin Office, Trent Building, Newcastle Road,
Stoke-on-Trent, ST4 6QG

Office Telephone:

Mobile Telephone:

01782 675292

07710 673965

Dr Alex Tabor, Consultant Paediatrician, Academic Department of Paediatrics,
Royal Stoke, University Hospital of North Staffordshire NHS Trust, 1st Floor Admin Office, Trent Building, Newcastle Road,
Stoke-on-Trent, ST4 6QG

Office Telephone: 

Mobile Telephone:

01782 675292    

07712 632322

Child Death Overview Panel Nurse Practitioners

For South Staffs (Part Time)
Rebecca Sage, Queen's Hospital,
Belvedere Road, Burton on Trent, DE13 0RB

Office Telephone 01283 511511 2354

For North Staffs
Gillian Devine-Skellern, Royal Stoke,
University Hospital of North Midlands NHS Trust, 1st Floor Admin Office, Trent Building, Newcastle Road, Stoke-on-Trent, ST4 6QG

Office Telephone


01782 679604

07775 704 899

I01 - Joint protocol Sudden Unexplained Death in Childhood (SUDIC) guidance

I02 Child Death Overview Panel forms

PART 10B When a Child Dies, Notification - Joint guidance between Stoke-on-Trent and Staffordshire Safeguarding Children Board

Preventing Child Death campaignsClick here to view the latest local campaigns

Coroners Contact Information:
The North Staffordshire and Stoke-on-Trent Coroner is Mr Ian Smith.

H M Coroner for Stoke-on-Trent and North Staffordshire
Coroner’s Chambers
547 Hartshill Road

Tel: 01782 234777    Fax: 01782 232074

Definition of preventable child deaths
For the purpose of producing aggregate national data, this guidance defines preventable child deaths as those in which modifiable factors may have contributed to the death. These factors are defined as those which, by means of nationally or locally achievable interventions, could be modified to reduce the risk of future child deaths.

In reviewing the death of each child, the CDOP should consider modifiable factors, for example in the family and environment, parenting capacity or service provision, and consider what action could be taken locally and what action could be taken at a regional or national level.

Definition of an unexpected death of a child
In this guidance an unexpected death is defined as the death of an infant or child (less than 18 years old) which was not anticipated as a significant possibility for example, 24 hours before the death; or where there was a similarly unexpected collapse or incident leading to or precipitating the events which lead to the death. 


The Regulations relating to child death reviews
The Local Safeguarding Children Board (LSCB) functions in relation to child deaths are set out in Regulation 6 of the Local Safeguarding Children Boards Regulations 2006, made under section 14(2) of the Children Act 2004. The LSCB is responsible for:

a) collecting and analysing information about each death with a view to identifying— 

  1. any case giving rise to the need for a review mentioned in regulation 5(1)(e);
  2. any matters of concern affecting the safety and welfare of children in the area of the authority;
  3. any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area; and 

b) putting in place procedures for ensuring that there is a coordinated response by the authority, their Board partners and other relevant persons to an unexpected death.

Specific responsibilities of relevant bodies in relation to child deaths

Registrars of Births and Deaths (Children and Young Persons Act 2008)

  • Requirement to supply the LSCB with information which they have about the death of persons under 18 they have registered or re-registered.
  • Notify LSCBs if they issue a Certificate of No Liability to Register where it appears that the deceased was or may have been under the age of 18 at the time of death.  Requirement to send the information to the appropriate LSCB (the one which covers the sub-district in which the register is kept) no later than seven days from the date of registration.

Coroners (Coroners Rules 1984 (as a mended by the Corners (Amendment) Rules 2008

  • Duty to inquire and may require evidence.  Duty to inform the LSCB for the area in which the child died within three working days of the fact of an inquest or post mortem.  Powers to share information with LSCBs for the purposes of carrying out their functions, including reviewing child deaths and undertaking SCRs.

Register General (Section 32 of the Children and Young Persons Act 2008)

  • Power to share child death information with the Secretary of State, including about children who die abroad.

Medical Examiners (Coroners and Justice Act 2009)

  • It is anticipated that from 2014 Medical Examiners will be required to share information with LSCBs about child deaths that are not investigated by a coroner.

Clinical Commissioning Groups (Health and Social Care Act 2012)

  • Employ, or have arrangements in place to secure the expertise of, consultant paediatricians who designated responsibilities are to provide advice on: commissioning paediatric services from paediatricians with expertise in undertaking enquiries into unexpected deaths in childhood, and from medical investigative services; and the organisation of such services.

Sources of Family Bereavement

Bereavement Support in Staffordshire and Stoke-on-Trent
Where to get advice and information:

Child Bereavement UK – Rebuilding lives together. Support and Information  

If you are the parent of a baby or child who has died, we can provide booked telephone support sessions for you as an individual or couple with a qualified counsellor. Please call us to find out more.
Telephone: 0800 02 888 40, Email:
For details about the direct support Child Bereavement UK can offer.

A Child of Mine – Help for Bereaved Parents
Telephone: 07803 751229 Office hours: Monday - Friday, 9am - 5pm. Out of hours leave a message and your call will be returned as soon as possible.

Donna Louise Hospice –Staffordshire
Offers a network of specialist care and support to children and young people who have life limiting or life threatening illnesses, and their families; includes bereavement support 01782 654440.

Bereavement counselling and support 01782 683 155.

The Lullaby Trust (formerly FSID)
Offers confidential support to family, friends and carers affected by the sudden and unexpected death of a baby or toddler: Tel: 0808 802 6868.
Calls to the Helpline are free from all landlines and most mobile phone networks. The Helpline is open: Monday – Friday 10am-5pm, Weekends and public holidays 6pm–10pm
(answered by trained befrienders, all with personal experience of bereavement)
The Helpline does not offer a formal counselling service but rather the opportunity to talk freely, for as long as required, with a sympathetic and understanding listener.
They can also offer support through their team of befrienders. Befrienders are themselves bereaved parents, grandparents and other relatives, who offer personal support which can be arranged via the Helpline.

Winston’s Wish
The largest charity provider of support to bereaved children, young people and their families in the UK. 08452 03 04 05

CLIC Sargent  Helping children and young people with cancer 0300 330 0803

Child Death Helpline
A freephone service offering support for anyone affected by the death of a child. 0800 282 986

Stillbirth and Neonatal Death organisation supporting anyone affected by the death of a baby. 02074365881

Information, support and counselling for families with babies “born too small, too soon, too sick”. 0500 618 140

CRUSE Bereavement Care
Helpline 0844 477 9400
Saying Goodbye,
National remembrance services, 0845 293 8027

I03  When a Child Dies

The majority of sudden unexpected deaths in infancy are natural tragedies, but a minority are a consequence of ignorance, neglect or abuse. Investigations should keep an appropriate balance between medical and forensic requirements and should take account of possible risks to other children in the household.

Professionals should approach with an open mind and families should be treated with sensitivity, discretion and respect.

There should be a multi-agency approach involving collaboration among: emergency department staff, ambulance, staff, child protection co-ordinators, coroners, coroners officers, GP's , health visitors, midwives, paediatricians, pathologists, police and social workers.

Over the years, detailed study of sudden infant deaths has led to the recognition of factors that are of importance in understanding and preventing such tragedies (e.g. the infant's sleeping position, parental smoking, and inappropriate sleeping environments). It is therefore important that this investigative approach is emphasised in all dealings with the bereaved family. The increasing ability to identify metabolic and other medical causes of sudden death in infancy and the mounting (and reasonable) expectation of parents that such conditions should be identified requires a wide and up to date knowledge of the familiarity with the literature in this field, together with considerable experience in the recognition of particular patterns of presentation of different conditions. Sudden unexpected deaths in infancy (SUDI) are now far less common than in the past.

The Staffordshire and Stoke-on-Trent Multi agency Protocol gives guidance for sudden and unexpected deaths and how each agency should respond. 

Related Files:

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