Child Death Overview Process – CDOP


Each death of a child is a tragedy for his or her family, and subsequent enquiries / investigations should keep an appropriate balance between forensic and medical requirements and the family’s need for support.

A minority of unexpected deaths are the consequence of abuse or neglect or are found to have abuse or neglect as an associated factor. Across the Luton and Bedfordshire, all statutory agencies are committed to working together to conduct coordinated enquiries.

Government legislation since April 2008 require LSCB’s to review the death of every child (from 0 up to the age of 18) in the area. This reflects the need to learn any lessons that may help to reduce child deaths in the future.

The Panel

The Child Death Overview Panel meets every six weeks and all child deaths are reviewed and it is responsible for collecting and analysing information about the death of every child under 18 years in Luton and Bedfordshire with a view to:

  • Identifying any matters of concern affecting the safety & welfare of children in the area
  • Identify any wider public health or safety concerns arising From a particular death or pattern of deaths the area
  • Identifying any case that should be considered as a Serious Case Review

It also has the job of overseeing the process of conducting a rapid response by a group of key professionals to enquire into and evaluate each unexpected death of a child.

Unexpected Deaths – Rapid Response Procedure

An unexpected death is defined as the death of an infant or child which was not anticipated as a significant possibility i.e. 24 hours before the death or where there was a similarly unexpected collapse leading to or precipitating the events which led to the death.

Whenever an unexpected death of a child occurs, a multi-agency response is initiated including a lead Consultant Paediatrician, a Bedfordshire Police Senior Investigating Officer, A & E staff, ambulance staff, GPs, social care, health visitors and the Coroner to enquire into the circumstances of the death, determine who will support the family and ensure there are no safeguarding concerns for other children in the family.

A decision will be made as to which professional will take the lead. This would be the police where there are apparent suspicious circumstances or other external factors. The lead Paediatrician would usually take the lead where there are apparent health or medical factors which have resulted in the death of the child.

Data Collection & Analysis

The Department for Education (DfE) coordinates the national data gathering procedures for every child who dies and publishes a set of templates for use by CDOP’s to facilitate and standardise the local, regional and national data collection process. The Panel will consider whether there were any modifiable factors identified during the review of the death.

Modifiable Factors

The panel have identified one or more factors, which may have contributed to the death of the child and which, by means of locally or nationally achievable interventions, could be modified to reduce the risk of future child deaths. These modifiable factors will help inform the public health agenda and inform staff of the emerging themes arising from the review of child deaths.


How does the CDOP define child death categories?

Neonatal Death
Death of a baby within the first 28 days of life

Sudden Unexpected Death in Infancy (SUDI)
Sudden death of an infant under the age of 1year which was not anticipated by any professional in the 24hours prior to the event which lead to the death

Unexpected death
A death which was not anticipated as a significant possibility for example 24 hours before the death
Where there was a similarly unexpected collapse or incident leading or precipitating the events which led to the death

Expected death
Death of a child with a known life limiting condition

Who sits on the CDOP panel?

  • Independent Chair Director of Public Health in Luton
  • 2 Lead Paediatricians for Child Death Reviews
  • Designated Nurses for Safeguarding Children
  • Police
  • Representatives from Children’s Social Care in Bedford Borough, Central Bedfordshire & Luton
  • Ambulance Service
  • LSCB Business Managers
  • Child Death Review Nurse for Luton
  • Public Health representative
  • CDOP Manager
  • Lay member

How can I find out more about the CDOP?

Multi-agency CDOP information awareness sessions are available for Luton Health Care professionals and Social Workers. Please contact for further information.

Information for Parents

As stated above, the death of any child is a tragedy. It is vital that all child deaths are carefully reviewed, so that we may learn as much as possible from them, to try to prevent future deaths, and to support families.

The Lullaby Trust has produced a leaflet for parents, which can be downloaded from the resources box on this page.