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Developing effective child death review: a study of ‘early starter’ child death overview panels in England
  1. Peter Sidebotham1,
  2. John Fox2,
  3. Jan Horwath3,
  4. Catherine Powell4
  1. 1Health Sciences Research Institute, University of Warwick, Coventry, UK
  2. 2Independent Trainer, Hampshire, UK
  3. 3University of Sheffield, Department of Sociological Studies, Sheffield, UK
  4. 4Portsmouth City Teaching PCT, Portsmouth, UK
  1. Correspondence to Dr Peter Sidebotham, Health Sciences Research Institute, University of Warwick, Coventry CV4 7AL, UK; p.sidebotham{at}


Aim This qualitative study of a small number of child death overview panels aimed to observe and describe their experience in implementing new child death review processes, and making prevention recommendations.

Methods Nine sites reflecting a geographic and demographic spread were selected from Local Safeguarding Children Boards across England. Data were collected through a combination of questionnaires, interviews, structured observations, and evaluation of documents. Data were subjected to qualitative analysis.

Results Data analysis revealed a number of themes within two overarching domains: the systems and structures in place to support the process; and the process and function of the panels. The data emphasised the importance of child death review being a multidisciplinary process involving senior professionals; that the process was resource and time intensive; that effective review requires both quantitative and qualitative information, and is best achieved through a structured analytic framework; and that the focus should be on learning lessons, not on trying to apportion blame. In 17 of the 24 cases discussed by the panels, issues were raised that may have indicated preventable factors. A number of examples of recommendations relating to injury prevention were observed including public awareness campaigns, community safety initiatives, training of professionals, development of protocols, and lobbying of politicians.

Conclusions The results of this study have helped to inform the subsequent establishment of child death overview panels across England. To operate effectively, panels need a clear remit and purpose, robust structures and processes, and committed personnel. A multi-agency approach contributes to a broader understanding of and response to children's deaths.

  • Child
  • adolescent
  • child death review

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  • Funding The study was funded by the Department for Children, Schools and Families (formerly Department for Education and Skills). This funding was awarded in open tender and the Department had no involvement in the study design, conduct or analysis. The views expressed in this paper are those of the authors and do not necessarily represent those of the Department for Children, Schools and Families.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.