Nov 03

SW London Child Death Overview Panel Report Published

This report is a collaboration of the activities of South West London CCG Partnership Child Death Overview Panels of Croydon, Kingston and Richmond upon Thames, Merton, Sutton, and Wandsworth. 

The new working arrangements for Child Death Overview Panels statutory and operational guidance (2018), sets out the key features of a good Child Death Review (CDR) process to be followed by all organisations involved with the process of child death reviews as of 1st April 2019.. South West London CDR partners implemented this guidance and started regional operations in September 2019.

The geographical ‘footprint’ of child death review partners has been locally agreed to cover a child population that typically reviews a minimum of at least 60 – 120 deaths per year. The amalgamation of panels is to provide a larger cohort of information to enable better detection of themes, analysis of trends, and learning to prevent future child deaths.




During this reporting period, there were 83 notifications of death, and 83 child death reviews. As of 1st April 2020, there are 70 open cases remaining making a total of 153 cases recorded on the South West London Child Death Overview Panel database.








Seventy-four percent (74%) of child deaths were classified as expected. Eighty Two Percent (82%) of these deaths had no modifiable factors identified. Twenty Four percent (24%) of child deaths were unexpected in South West London, and eighteen (18%) percent had modifiable factors identified. Thirty-one unexpected child deaths had Rapid Response/Joint Agency meetings held across South West London.





Recommendations and learning from panel reviews contributed to promotion in community education, improvements in organisational practice, improvements in education, training, and communication in local partner agencies, and learning that has had an impact on national government policy.

Read the full report here: SWL CDOP Annual report 2019-20

NHS South London
Met Police
NHS Croydon Health Services
NHS Croydon Clinical
Safer London