Lincolnshire Child Death Overview Panel Terms of Reference
The Child Death Overview Panel will fulfil the requirements as described in Chapter 5 of
Working Together to Safeguard Children to collect and analyse information about every
death of a child aged under 18 years of age in Lincolnshire with a view to:
identifying any matters relating to the death or deaths that are relevant to the
welfare of children in the area and to public health and safety
considering whether it is appropriate for any action to be taken by anyone in relation
to their findings
taking action to inform the necessary person
to collect and collate information about each child death, seeking relevant
information from professionals;
to analyse the information obtained, including the report from the Child Death
Review Meeting (CDRM), in order to confirm or clarify the cause of death, to
determine any contributory factors, and to identify learning arising from the child
death review process that may prevent future child deaths;
to make recommendations to all relevant organisations where actions have been
identified which may prevent future child deaths or promote the health, safety and
wellbeing of children;
to notify local Safeguarding Partners when it suspects that a child may have been
abused or neglected;
To notify the Significant Incident Review Group (sub-group of the LSCP) where
there has been an incident that may require further review, this may include
examples of good practice.
to notify the Medical Examiner (when appointed) and the doctor who certified the
cause of death (to be removed when Medical Examiner appointed), if it identifies
any errors or deficiencies in an individual child's registered cause of death. Any
correction to the child’s cause of death would only be made following an application
for a formal correction;
to provide specified data to NHS Digital and then, once established, to the National
Child Mortality Database;
to produce an annual report for CDR partners on local patterns and trends in child
deaths, any lessons learnt and actions taken, and the effectiveness of the wider
child death review process; and
to contribute to local, regional and national initiatives to improve learning from child
death reviews, including, where appropriate, approved research carried out within
the requirements of data protection.
Additionally, the Lincolnshire CDOP will:
Monitor and evaluate routinely collected data on the deaths of all children, and
make recommendations for any additional data to be collected locally.
Identify any Public Health issues, and consider with the Lincolnshire Director of
Public Health and/or LSCP how best to address these and their implications for both
the provision of services and for training.
Monitor and advise the Lincolnshire LSCP on the resources and training required
locally to ensure an effective inter-agency response to child deaths.
M e mbership
The following will be members of the Child Death Overview Panel;
Job Title
Dr Julian Saggiorato (Chair)
Designated Doctor for Children and
Dr Mujeeb Pervez (Vice
Consultant in Community
Paediatrics/SUDIC Lead, Pilgrim
Hospital Boston
Andy Fox
Acting Consultant in Public Health,
June Nur
Deputy Named Nurse
Penny Snowden
(Julie Bulteel acts as
Divisional Head of Midwifery & Nursing
Coroner for Lincolnshire
HM Coroner
Dr Margaret Crawford
Named Doctor
Jo Casey
(Phillipa Gallop acts as
Children's Services Manager East
Claire Saggiorato
Children's Safeguarding Lead Nurse
Perce Bosworth/Helen
Quality Auditor and SCR Author
Lincolnshire Police
Dr Frances Senthil
Named Doctor
Business Support
Administrator & Minutes
Case Specific/Optional Membership:
Job Title
Steven Batchelor
LRSP Manager
Road Safety
Jill Chandar-Nair
Children's Services - Education
Lincolnshire County
Clare Rowley
Business Manager
Zoe Rodger-Fox / Lucy
Head of Safeguarding / Head of Child
and Young Person Safeguarding
Dr Rahab Omer
Community Paediatrician/SUDIC Doctor
Other members may be co-opted as appropriate.
The Lincolnshire LSCP will select one of its members to chair the panel, annually at the
The Child Death Overview Panel is a sub-committee of the Lincolnshire LSCP.
The frequency of panel meetings should aim to enable the circumstances of all child deaths
to be discussed within 6 weeks following receipt of the Child Death Review Meeting (CDRM)
such as the SUDIC or hospital mortality meeting, or from conclusion of a Coroner's inquest.
For the most part, the meetings should take place at least quarterly. Where the number of
deaths is low, the panel meeting can be deferred for up to 3 months (minimum 4 panel
meetings a year).
Where other investigations are ongoing that will be likely to inform the overview, such as
criminal investigations or serious case review, the case may be deferred until 6 weeks after
these have been concluded.
Administrative support will be provided by the Lincolnshire LSCP.