The death of a child is always devastating. For those working with children and families, it’s important that we take the time to understand what happened, not only to support those affected, but to learn how we can reduce the risk of future harm.

The Child Death Overview Panel (CDOP) is part of this process. It brings together professionals from different services to carefully review every child death. The aim is to build a clear picture of the circumstances, look at any factors that may have contributed, and identify what could be done differently in the future.

Learning from child deaths is a key part of safeguarding. It helps us reflect on our work, spot patterns or risks, and improve how we support children and families. This learning is shared across services so that it can strengthen practice and lead to real changes locally and beyond.

On this page, you will find practical guidance on the Child Death Overview Panel process in South Tyneside, including what happens at each stage, what is expected of practitioners, and how learning is captured and used to improve services.

Child Death Overview Panel (CDOP): Role, Process, and Learning

Role and Function

The Child Death Overview Panel (CDOP) is a statutory multi-agency panel established under the Children Act 2004 and guided by Working Together to Safeguard Children 2026. Its purpose is to review all deaths of children (up to 18 years, excluding stillbirths and planned terminations) who are normally resident in South Tyneside and the wider North & South of Tyne footprint.

The panel’s key functions are to:

• Ascertain why a child has died through a proportionate review of circumstances.
• Identify contributory and modifiable factors.
• Make recommendations to prevent future deaths and improve child health and safety.
• Share learning locally, regionally, and nationally.
• Provide data to the National Child Mortality Database (NCMD) for national analysis.

The Process

When a child dies:

1. Immediate decisions are made by clinicians regarding certification or referral to the coroner.
2. Information is gathered from all agencies involved and collated.
3. A Joint Agency Response (JAR) may be held for unexpected deaths.
4. A Child Death Review Meeting (CDRM) considers all available information.
5. The CDOP reviews the case, classifies the cause of death, and identifies modifiable factors.
6. Recommendations are made to relevant agencies to improve practice and prevent future deaths.

What Are Modifiable Factors?

A modifiable factor is something that:

“May have contributed to the death of the child and which, by means of locally and nationally achievable interventions, could be modified to reduce the risk of future child deaths.”

Examples include:

• Social environment: parental smoking, substance misuse, lack of supervision.
• Physical environment: unsafe sleeping arrangements, road safety issues.
• Service provision: missed opportunities for intervention, communication failures.
• Intrinsic factors: health conditions, risk-taking behaviour.

Why Learning Matters

Every child death is a tragedy. Learning from these reviews helps:

• Identify patterns and risks.
• Inform public health strategies (e.g., safer sleep campaigns, smoking cessation).
• Improve professional practice and service delivery.
• Reduce preventable deaths and promote child wellbeing.

South Tyneside Summary

In 2024/25, 13 child deaths were reviewed in South Tyneside. Modifiable factors were identified in 54% of cases, highlighting the importance of prevention strategies such as safer sleep advice, smoking cessation, and improved communication between agencies.

Further Information

Read the full North & South of Tyne CDOP Annual Report 2024/25 for detailed data and learning

• CDOP Annual Report