Skip to content

Child Deaths

The death of a child is always tragic. Talking and thinking about a child's death is a sensitive and painful subject which is particularly upsetting for parents, families and carers.

The responsibility for ensuring child death reviews are carried out is held by the child death review partners (LA and CCG) within the local area. Child death review partners must make arrangements to review all deaths of children and young people (under 18 years) normally resident within the local area and make arrangements for the analysis of information from all child deaths.

The Child Death Overview Panel (CDOP)

The Child Death Overview Panel (CDOP) is a multi-agency statutory requirement of local child death review partners who review all deaths in children and young people. City of York and North Yorkshire Safeguarding Children Partnerships work together to co-ordinate the review of child deaths and share learning to help safeguard children.

This statutory process has been in place since 2008 with guidance recently been updated in Working Together to Safeguard Children 2018, Chapter 5 and the Child Death Review Operational and Statutory Guidance 2018 published by NHS England in October 2018.

 It is intended that the Child Death Review process will:

  • Document and try to understand the cause of death so that parents/guardians and the wider family can come to terms with the death of their child.
  • Enable parents/guardians and professionals to take steps to prevent the deaths of any other children where possible.
  • Identify patterns of deaths in a community so that preventable or avoidable hazards that may contribute to deaths can be recognised and reduced.
  • Contribute to the improved collection of forensic evidence in the very small proportion of deaths where there might be concerns about the cause of death being non-accidental. 

How to notify a child death

Professionals who become aware of a child death must notify, within 48 hours:

The Child Death Review Officer

Ali Firby

T: 01609 797167 / M: 07967 469790

Notification should be made using the Notification of Child Death Form  or the Child Death Online Notification Form, including as much information as possible and return to

This is the latest form which has been updated nationally due to the outbreak of coronavirus (COVID-19)

North Yorkshire Safeguarding Childrens Partnership Child and Family Bereavement Support

North Yorkshire Safeguarding Childrens Partnership Child and Family Bereavement Support

National Learning

The National review into sudden unexpected death in infancy in families where children are considered at risk of significant harm was published on 21st September 2020.  

Child Death Review Training

Training is available to York practitioners free of charge.  Please note these courses are arranged by North Yorkshire Safeguarding Children Partnership.   Please see further information including how to book on the CYSCP Multi-Agency Training course webpage.

Useful Links

Child Death Review Statutory and Operational Guidance

North Yorkshire and City of York Child Death Review Arrangements

NHS England “When a Child Dies” Booklet 

Sudden - supporting people after sudden death

Our Advice for Parents and the Public - supporting and safeguarding children has a section on Grief:

The National Child Mortality Database.   The National Child Mortality Database (NCMD) is an NHS funded programme, delivered by the University of Bristol, that gathers information on all children who die in England. They aim to learn lessons that could improve and save children’s lives in the future.

CDOP Annual Report


CDOP Annual Report 2020 - 2021

Safety Notices

The National Child Mortality Database (NCMD) have launched a new section of their website, where safety notices will be published on a regular basis.  Designed to highlight key risks posed to babies and children, the section has been designed for professionals supporting families to have a one-stop place where they can go to see the latest safety updates, and obtain information on what to do to mitigate those risks. 

The current safety notices that professionals working with children and families should be aware of are;

Water safety

Water is fun but can be dangerous to children, including older children. The sea, pools, ponds and any standing water all pose a threat so it is important that children are watched and are never alone when around water.

Face masks (COVID-19)

Face masks are NOT considered to be suitable for young children and babies, and can pose a danger to life - it is particularly relevant to share this information during the COVID-19 pandemic.

Nappy sacks

Extremely dangerous to babies and young children, they can cause suffocation if near the mouth and nose. Never leave in a child’s room - even if thought to be out of reach - and make sure that they cannot be accessed.

Equipment for babies; keep it simple

Always follow the manufacturer’s instructions and avoid enhancements unless recommended. With cots, it is safest to keep them clear of items such as bumpers, toys and loose bedding.

Blind and curtain cords

Cords on blinds, curtains and similar items must be kept short and out of reach of children, particularly in a child's bedroom or near a cot. They are extremely dangerous to children and babies as they can cause strangulation.