Croydon
Child Death Overview Panel
Sixth Annual Report 2013/2014
Contents
1Introduction5
2Background5
3Organisation of Croydon Child Death Overview Panel6
3.1The Process6
3.2Panel Meetings7
3.3Administration8
3.4Representation8
4Definitions and categories of child death 8
4.1Neonatal Death8
4.2Sudden Unexpected Death in Infancy (SUDI)8
4.3Expected Death8
4.4Unexpected Death8
4.5Modifiable Death8
5National picture9
6Local picture9
6.1Number of Deaths in CDOP area9
6.2Time from child death to CDOP review9
6.3Neonatal deaths10
6.4Expected and unexpected deaths10
6.5Sudden Unexpected deaths in Infancy (SUDI)11
6.6Modifiable Factors11
6.7Serious Case Reviews and Serious Incident Learning Process11
6.8Age and Gender12
6.9Ethnicity12
6.10Cause of Death13
6.11Deprivation14
6.12Place of Death14
6.13Asylum seekers15
6.14Post mortem examination carried out15
7Rapid Response15
8Bereavement services for families16
9Directly standardised mortality rates16
10Summary of child death reviews 2013/201417
11Recommendations to the CSCB following CDOP reviews in 2013/2014 17
11.1Issues identified17
11.2Learning points18
11.3Good Practice18
12Feedback on outstanding issues from previous report 2012/2013 18
13Actions completed for 2013/201417
14Actions for 2014/201519
15Appendices20
15.1Appendix 1: CDOP Terms of Reference20
15.2Appendix 2: Rapid Response Meeting Terms of
Reference23
15.3Appendix 3: Rapid Response Meeting Agenda27
15.4Appendix 4: Rapid Response Process28
Tables
Table 1: Panel member attendance at CDOP meetings 2013/20147
Table 2: Neonatal deaths by gender, expected and unexpected
2013/201410
Table 3: All child deaths reviewed in 2013/2014 by gender, expected,
unexpectedand SUDI11
Table 4: All child deaths reviewed in 2013/2014 by gender and age12
Table 5: All child deaths reviewed in 2013/2014 by ethnicity12
Table 6: All child deaths reviewed in 2012/2013 and 2013/2014 by ethnicity 13
Table 7:Location at time of event or condition15
Table 8: Number of Rapid Response meetings and Child death
reviews by the CDOP in 2012/2013 and 2013/201416
Table 9: Comparison of directly standardised mortality rate per
100,000children aged 1 – 7 years 2010-201217
Figures
Figure 1: Length of time to complete reviews 2013/201410
Figure 2: Expected and unexpected deaths reviewed by age
2013/201411
Figure 3: Cause of death by category 2013/201412
Figure 4: Child deaths reviewed in 2013/2014 by deprivation quintile
(Index of Multiple Deprivation)13
1Introduction
Welcome to the sixth annual report of the Croydon Child Death Overview Panel (CDOP) which sets out the activities of the CDOP from 1st April 2013 – 31st March 2014.
The aim of this report is to provide a summary of the work of the CDOP during 2013/2014.The numbers in this report refer to the child deaths that have been reviewed within this time period.
Recommendations and learning points from the overview of deaths are provided within this report to which the CSCB (Croydon Safeguarding Children Board) has a responsibility to respond and take action; ensuring that they are included in future education and interventions that could help prevent future child deaths, or improve the safety and welfare of children within the borough.
Due to the small numbers of child deaths reviewed, associations and significance cannot be applied to the findings. Details may also be omitted as these would breach confidentiality.
2Background
Fortunately, it is rare for children to die in this country but each child death is a sad and serious event.
Nationally, CDOPs were established in April 2008 as a statutory requirement[1].Theprimary functionis to undertake a local review of all child deathsunder the age of18 (excluding stillbirths and terminations of pregnancy carried out within the law) so that lessons can be learnt with the aim of preventing similar deaths happening in the future. Working Together to Safeguard Children[2] was revised and reissued in March 2013 however, the responsibilities of the child death overview process remains unchanged.
The CDOP has specific functions laid down by statutory guidance:
- Meet regularly to review the available information on all child deaths to determine whether the death was preventable.
- Collecting,collating and reporting on an agreed national data set for each child who has died.
- Identify lessons to be learnt or issues of concern relating to the safety and welfare of children in Croydon
- Make recommendations to the CSCB regarding any deaths where the panel considers there may be grounds for a serious case review
- Monitoring the support services offered to bereaved families
- Identify any PH issues, patterns or trends in local data
- Report any immediate concerns to the CSCB that require a
co-ordinated response to ensure the safety and well-being of all
children in Croydon
See Appendix 1 for CDOP Terms of Reference.
3Organisation for Croydon CDOP
3.1The Process
The death of each child is notified to the Child Death Review Co-ordinator (CDRC) who is also the SPOC (Single Point of Contact)via a telephone call or other verbal/electronic means; this is followed with“Form A” giving initial details about the death. The designated paediatrician will then consider whether the death was unexpected and if deemed to be so, will initiate a rapid response.
See Appendix 2for Rapid Response Meeting Terms of Reference.
For all children who die, whether expectedly or unexpectedly, an information gathering process is initiated. The completion of “Form B” (data collection form)is requested from all agencies and services involved in the death in order to provide as full a picture as possible of the circumstances directly and indirectly leading to the death.
Whilst using information from a number of existing forms and sources e.g. neonatal unit summary/ discharge summary, hospital death summary, police forms, post mortems and rapid response meeting minuteshas helped to improve the available information, on-going difficultiesremain in obtaining a completed Form B from many of the agencies.
CDOP meetings are convened regularly at which the review of a child death will be included if the information gathered is felt to be as complete as expected and where relevant a post mortem, coroner’s report and rapid response meeting report, have been returned.
The CDOP core members are invited to attend every meeting; invites to additional agency representatives will be made where the panel feel this would be essential or advantageous for the overview to be conducted with additional expertise.
The CDOP discuss each case and, using “Form C” (Analysis Proforma),the discussions are recorded based on the information provided in the Form B and other supporting documentation, to give an overview of the findings of the case.
Data from Form C is entered onto a spreadsheet to support analysis of the data,points of interest for the CSCB and to inform this report.
Any identified learning and recommendations from the case reviews are communicated to the agencies involved, setting out the concerns and requesting feedback from the agency to confirm what actions have been/are being taken to address the concerns. The CSCB Chair is provided with the concerns and responses and will guide as to whether the Board are confident that appropriate measures have been taken to safeguard children in the future, or if further action needs to be taken.
3.2Panel Meetings
During 2013/2014, CDOP met five times to review anonymous information about child deaths. The panel is chaired by Public Health and has members from relevant agencies.
The CDOP has a fixed core membership of experts drawn from the key organisations represented on the Croydon Safeguarding Children Board who should be present at each meeting. Other members are co-opted to contribute to the discussion of certain types of death when they occur.
Table 1: Panel member attendance at CDOP meetings 2013/2014
Child Death Overview PanelAttendance
07/05/13 / 01/07/13 / 04/11/13 / 24/01/14 / 24/03/14
Public Health (Chair) / / / / /
Health (Croydon Health Services)
Designated Doctor: Children’s Safeguarding / × / / / /
Designated nurse: Children’s Safeguarding / / × / / / ×
Named Paediatrician: Child Protection / / × / × / × / ×
Named Nurse: Child Protection / × / / / /
Named Midwife: Safeguarding / × / / × / × / ×
Child Abuse Investigation Team Police (CAIT) / / / / / ×
Social Work Children & Families Service / / / × / /
Child Death Review
Co-ordinator / / / / /
Overall the meetings have been well attended. In 2013/2014; it was agreed that the roles of Designated Doctor for Children’s Safeguarding and Named Paediatrician would be combined; the Named Midwife for Safeguarding resigned from Croydon University Hospital and this role was not appointed to during 2013/2014. In November 2013, the Public Health representative who chaired the meetings retired and it was agreed that this role would be filled by another representative from Public Health Croydon.
In 2013/2014, a separate panel reviewed the neonatal deaths (babies aged less than 28 days) as the reasons such young babies die is nearly always health related, however, from December 2013, the process reverted back to where the cases are reviewed by the CDOP.
3.3Administration
The administration of the CDOP process is amalgamated with the Rapid Response Meetings and is hosted within Croydon Health Services whilst being funded by CSCB through the contributions of partner organisations.
3.4Representation
To ensure local, pan London and national co-ordination of, and input into, the CDOP processes, the CDOP Chair provides Croydon representation through local membership on the CSCB, the CSCB Executive Group and Health
sub-groups and attendance at the London CDOP Chairs’ meetings.
4Definitions and categories of child death
4.1Neonatal Death
The death of a child under 28 days of age, including premature births but excluding stillbirths.
4.2Sudden Unexpected Death in Infancy (SUDI)
The sudden death of an infant under one year that is unexpected by medical history and remains unexplained after a thorough post mortem examination and a detailed death scene investigation[(then referred to as Sudden Infant Death Syndrome (SIDS)].
4.3Expected Deaths
An expected death is that which was anticipated 24 hours before the death.
4.4Unexpected Deaths
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.[3]
4.5Modifiable death
A modifiable death is defined as where there are factors which may have contributed to the death. These factors are identified as those which by means of nationally or locally achievable interventions, could be modified to reduce the risk of future child deaths.
5National Picture
According to the Department of Education[4], whilst the number of deaths of children registered in England has continued to decline,there are just over 4000 child deaths a year; the main causes of death continue to beneonatal or perinatal events and chromosomal, genetic and congenital anomalies. This reflects the fact that nearly two-thirds of deaths wereto children who were under the age of one year.
Nationally in 2012/2013, 21% of all child deaths reviewed were identified as having modifiable factors.
Data taken over three years 2010/2011, 2011/2012 and 2012/2013, shows that 64% of deaths due to “deliberately inflicted injury, abuse or neglect” and 52% of deaths due to suicide or deliberate self-inflicted harm were identified as having modifiable factors.
6Local Picture
6.1Number of deaths in CDOP area
Between April 2013 and March 2014 the CDOP was notified of 37 child deaths compared with 34 in the previous year. In the same year the panel completed 36 reviews.
Of the 36 cases that were reviewed, six were children who died in 2011/2012,16 were children who died in 2012/2013 and 14were forchildren who died in 2013/2014. A further two cases were deferred to obtain further information to support the review.
At the time of writing this report, there are currently 22 cases awaiting review 3 for children who died in 2012/2013 and 19 cases for children who died in 2013/2014.
6.2Time from death of the child to CDOP review
The length of time from death to the panel review varied considerably with 10 cases being reviewed within the first 6 months following the death, 16 in the period 6-12 months and ten after one year of the death.
There is often a time lag between a death and the review whilst all relevant information needed for the review is gathered. The various reasons for the delays are:
- slow returns of Form Bs (data collection forms)
- time taken for the post mortem or coroner’s autopsy reports to be released
- awaiting the findings of criminal proceedings or Serious Case Reviews (SCR)
- the panel requested further information
Figure 1: Length of time to complete reviews 2013/2014
6.3Neonatal Deaths
Similar to the national picture, a large proportion of allneonatal deaths are accountable to maternal and neonatal factors; 14 (38.9%) of all deaths were to babies less than 28 days of age. Nine of these babies were born prematurely (<37 completed weeks’ gestation), and sixof thesebabies were born at 26 weeks’ or less gestation.
Out of the neonatal deaths there were eight females and six males. There were similar numbers of expected deaths for both females and males however, threeof the deaths of females were unexpected.
Table 2:Neonatal deaths by gender, expected and unexpected
2013/2014
Expected / Unexpected / Total(n) / (%) / (n) / (%) / (n) / (%)
Female / 5 / 45.5 / 3 / 100.0 / 8 / 57.1
Male / 6 / 54.5 / 0 / 0.0 / 6 / 42.9
Total / 11 / 100.0 / 3 / 100.0 / 14 / 100.0
6.4Expected and Unexpected Deaths
26 of the 36 child deaths reviewed could have been expected 24 hours before they occurred and the majority of these were in children under 1 year of age.
Similarly,six of the ten unexpected deaths occurred in children under one year of age.
Table 3:All child deaths reviewed in 2013/2014 by gender, expected, unexpected and SUDI.
Female / Male / Total(n) / (%) / (n) / (%) / (n) / (%)
Expected death / 13 / 50.0 / 13 / 50.0 / 26 / 72.2
Unexpected death / 5 / 50.0 / 5 / 50.0 / 10 / 27.8
Totals / 18 / 18 / 36
SUDI / 2 / 100.0 / 0 / 100.0 / 2 / 100.0
Figure 2: Expected and unexpected child deaths reviewed by age,
2013/2014
6.5Sudden Unexpected Deaths in Infancy (SUDI)
There were two sudden unexpected deaths in infancy, classified by the post mortem as sudden infant death syndrome during this time period.
6.6Modifiable factors
Of the 10 unexpected deaths, one was identified as having modifiable factors but no risk factors were identified in this case.
6.7Serious Case Review and Serious Incident Learning Process (SILP)
Of the children whose deaths were reviewed in this period,one was the subject of a SCR and one to a SILP .
- SCR – this child was undera current child protection plan at the time of their death.The overview report has been completed and the recommendations have been included within a multi-agency action plan.
- SILP- the review for this case has been completed but has not yet been published at the time of this report.
No other children whose deaths were reviewed in 2013/2014 were subject to a child protection plan.
6.8Age and gender
As expected, most of the deaths reviewed were to infants under one year of age: n= 26 (72.2%); 8 deaths were between 1 and 9 years and one death each in the 10 – 14 and 15 – 17 year age ranges.
Table 4: Child deaths reviewed in 2013/2014 by gender and age
Age at death / Female / Male / Total(n) / (%) / (n) / (%) / (n) / (%)
<28 days / 8 / 44.4 / 6 / 33.3 / 14 / 38.9
28 days - <1 year / 6 / 33.3 / 6 / 33.3 / 12 / 33.3
1 - 4 years / 2 / 11.1 / 2 / 11.1 / 4 / 11.1
5 - 9 years / 1 / 5.6 / 3 / 16.7 / 4 / 11.1
10 – 14years / 0 / 0.0 / 1 / 5.6 / 1 / 2.8
15 - 17 years / 1 / 5.6 / 0 / 0.0 / 1 / 2.8
Total / 18 / 100.0 / 18 / 100.0 / 36 / 100.0
During 2013/14 an equal number of females and males died in the cases reviewed.
6.9Ethnicity
Table 5 represents child deaths reviewed between April 2013 and March 2014 by ethnicity, expected/unexpected deaths and age.
Table 5: Child deaths reviewed in 2013/2014 by ethnicity
Table 6 shows that the Black and Asian Minority Ethnic (BAME) population represented 44.5% of the children 0-17 years who died compared to 62.5% in 2012/2013. This is below the projections for 2013[5]that show that 60.6% of Croydon’s population aged 0-17 years are from BAME groups. Compared with 2012/2013, there has been a percentage increase in mixed and white ethnic groups.
Table 6: Child deaths reviewed by ethnicity 2012/2013 and 2013/2014
Ethnicity / 2012/2013 / 2013/2014(n) / (%) / (n) / (%)
White / 5 / 20.8 / 10 / 27.8
Mixed / 2 / 8.3 / 9 / 25.0
Asian / 7 / 29.2 / 5 / 13.9
Black / 8 / 33.3 / 11 / 30.6
Other / 2 / 8.3 / 1 / 2.8
Totals / 24 / 36
6.10Cause of death
The majority of reviewed deaths under 1 year were due to perinatal or neonatal events including prematurity and/or hypoxia at birth. Of the deaths to children over 1 year, most were related to existing long term conditions.
Figure 3:Cause of death by category 2013/2014
6.11Deprivation
The index of multiple deprivation (IMD) is a method of ranking areas according to their level of deprivation by combining different indicators into a single score. It is calculated by combining different scores on a range of indicators relating to income, employment, health, education, housing and access to services. The most deprived fifth (quintile) of the population is described as “quintile 1” and the least deprived quintile is described as “quintile 5”
As seen in Figure 4,there are a greater number of children whose deaths were reviewed who were within the lower quintiles 1 to 3. No neonates reviewed were in the least deprived quintile.
Figure 4: Child deaths reviewed in 2013/2014 by deprivation quintile
(Index of Multiple Deprivation)
The greater proportion of children living within the lower IMD may be due to differences in factors affecting the determinants of health: personal, social, economic and environmental conditions or it may partly reflect the over representation of children within the most deprived population quintiles
6.12Place of death (based on the issuing of death certificate)
As would be expected the majority of children died in hospital, often following an event or deteriorating condition that took place at home. This reflects the high proportion of child deaths which were neonatal deaths and are likely to be children who have not left hospital since their birth.
There was one death in a public place; this case is subject to a SCR review, the outcome of which is awaited at the time of writing this report.
One infant who was born abroad and whose family relocated to Croydon was transferred to a London hospital for on-going care.
Two children received palliative care in a hospice.
Table 7: Location at time of event or condition
Location at time of event or condition / Under 28 days / Over 28 daysExpected / Unexpected / Expected / Unexpected / Total
(n) / (%) / (n) / (%) / (n) / (%) / (n) / (%) / (n) / (%)
Hospital / 9 / 81.8 / 2 / 66.7 / 6 / 40.0 / 0 / 0.0 / 17 / 47.2
Home / 2 / 18.2 / 1 / 33.3 / 7 / 46.7 / 6 / 85.7 / 16 / 44.4
Public Place / 0 / 0.0 / 0 / 0.0 / 0 / 0.0 / 1 / 14.3 / 1 / 2.8
Abroad / 0 / 0.0 / 0 / 0.0 / 1 / 6.7 / 0 / 0.0 / 1 / 2.8
Hospice / 0 / 0.0 / 0 / 0.0 / 1 / 6.7 / 0 / 0.0 / 1 / 2.8
Total / 11 / 100.0 / 3 / 100.0 / 15 / 100.0 / 7 / 100.0 / 36 / 100.0
6.13Asylum Seekers
In 6 (16.7%) of the reviews completed the asylum seeker status was unknown. 3 (8.3%) of child deaths reviewed were for children seeking asylum.
6.14Post mortem examination carried out
Of the 36 deaths, 11 had a post mortem carried out.
Of the 14 neonatal deaths only two had a post mortem carried out.Of those who did not have a post-mortem examination, two were unexpected deaths in neonates and twowere unexpected deaths of children older than 28 days. In two other deaths reviewed, where a post-mortem was not needed, the cause of death was clear to the medical practitioners. All the remaining unexpected deaths had a post mortem to determine or confirm the cause of death.
7Rapid Response
The arrangements for a rapid response to the death of a child and review are well established in Croydon.