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Improving the practice of child death overview panels: a paediatric perspective
  1. Luke Allen1,
  2. Simon Lenton2,
  3. James Fraser3,
  4. Peter Sidebotham4
  1. 1Department of Medicine, Royal Cornwall Hospital, Truro, Cornwall, England
  2. 2Community Child Health Department, NHS House, Bath, England
  3. 3Department of Paediatric Intensive Care, Bristol Royal Hospital for Children, Bristol, England
  4. 4Warwick Medical School, Coventry, England
  1. Correspondence to Dr Luke Allen, Department of Medicine, Royal Cornwall Hospital, Truro, Cornwall TR1 3LJ, England; drlukeallen{at}


Objective In England, every death in childhood is reviewed by a local multidisciplinary Child Death Overview Panel (CDOP) with the intention of understanding causation and implementing interventions to reduce future deaths. This study aimed to establish how well panels work from the perspective of the paediatricians involved and to ascertain whether they deliver good value and identify areas for improvement.

Design A questionnaire was sent to every CDOP paediatrician in the country (n=93). Questions focused on the quality of CDOP case discussions as well as examples of effective and significant recommendations. Responses were analysed using simple quantitative and qualitative methods.

Results 84/93 (90%) of the paediatricians responded. Among the respondents, 60 (71%) believe that investment in CDOPs is offering good value, 73 (87%) feel that case discussions are rigorous and consistent and over 90% believe that the correct issues are emerging from discussions. However, responders noted many areas for improvement: 40 (48%) suggested devolving the discussion of specialist deaths (eg, neonates) to hospital-based review meetings or holding themed meetings with invited specialists, 11 (13%) suggested filtering out cases where learning is unlikely before full CDOP meetings and 13 (15%) called for national integration and analysis of data.

Conclusions In this time of economic austerity it is vital that the CDOPs add value to the invested resources. Although CDOP paediatricians feel that panels are working well, there is scope for improvement through enhancing relationships with commissioning bodies, aggregate review and analysis of CDOP data at a national level and consideration of specialist and/or network review of certain categories of deaths such as cardiac surgery, oncology and neonates.

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