Child Deaths


The Surrey Safeguarding Children Board (SSCB) has responsibility for reviewing the deaths of all children who live in Surrey, other than still births or planned terminations that are within the law, through the arrangements of a Child Death Overview Panel (CDOP) (Working Together 2018).

The Panel has a fixed core membership drawn from organisations represented on the SSCB with flexibility to co-opt other relevant professionals to discuss certain types of death as and when appropriate. It is chaired by the Deputy Director of Public Health. The panel meets bi monthly to review each death and includes representatives from Public Health, Designated Doctor for Child Deaths, Designated Doctor for Safeguarding Children, Specialist Nurse Child Deaths, Named GP, Police, Children’s Services, Ambulance Service, Education and Specialist Bereavement/Hospice.

The purpose of the child death review process is to collect and analyse information about the death of each child who normally resides in Surrey with a view to identifying any matters of concern affecting the health, safety, or welfare of children, or any wider public health concerns. The overall purpose of the child death review process is to understand why children die, put in place interventions to protect other children, prevent future deaths and to support families.

In order to fulfil its responsibilities CDOP should be informed of all deaths of children, normally resident in the geographical area.

Notification of a child death

CDOP must be notified within 24 hours of a child’s death. As soon as a professional becomes aware of a child death they should notify the Surrey Single Point of Contact by completing and returning a Form A Notification of Child Death and a Form B Agency Report

Single Point of Contact

CDOP Coordinator
Tel: 01372 833319      

Rapid Response

When a child dies unexpectedly, a Rapid Response procedure is initiated by key professionals. This is a coordinated response to accurately investigate the circumstances regarding the child’s death and ensure the family is supported. An unexpected death is defined as the death of an infant or child (less than 18 years old) which was not anticipated as a significant possibility 24 hours before the death or where there was a similarly unexpected collapse or incident leading to or precipitating the events which led to the death.

Annual Report

Please see the SSCB Annual Report, which includes CDOP recommendations for learning and preventing child deaths in Surrey.

Surrey CDOP Report regarding reducing infant mortality in Surrey

Requests for information on child deaths is reviewed on a case by case basis. Please contact the CDOP Coordinator at or call 01372 833319.

Supporting Documents

CDOP Flowchart

Child Death Review Protocol

MOU between HM Senior Coroner for Surrey and Surrey CDOP

Post Death Review Agenda (Rapid Response)

How we review when a child dies – Surrey information leaflet for parents, families and carers

How we review when a child dies unexpectedly – Surrey information leaflet for parents, families and carers

Support and Bereavement Services can be found on our parents and carers and children and young people web pages

Oasis Study

A study that is being undertaken into the possible relationship between the Newborn Hearing Screening Test and the risk of unexpected infant deaths.

The Oasis study is being funded by The Lullaby Trust and is being led by Professor Peter Fleming, Professor of Infant Health and Developmental Physiology, Consultant Paediatrician, University of Bristol whose career has been dedicated to reducing unexpected deaths in infants and children.


A study conducted in the USA in 2007 showed differences in the Newborn hearing test results of babies who subsequently died as SIDS compared to babies who survived. These results need to be confirmed with UK data but one possibility is that these differences are signalling an injury to the brainstem which may lead to abnormalities of the control of breathing, temperature control or blood pressure. If the US study is correct, it may be possible to identify a proportion of the infants or young children at high risk of unexpected death, offering the possibility of advice and monitoring that may prevent some of these deaths.

The study has now commenced and The Lullaby Trust would like to speak confidentially to any family whose baby or young child died suddenly and unexpectedly after 1st January 2010 and who might be interested in contributing to this research. Please call Catherine Taylor at The Lullaby Trust on Tel: 020 7802 3219 if you would like to be part of this important research and she will be able to give you more information and answer some of your questions. 

The Specialist Nurse for Child Death Reviews in Surrey will be writing to families in Surrey known to have lost a child as a result of SIDS to inform them of the research and inviting them to participate in the study should they wish to do so.

Further information is available at: