Barking and Dagenham Child Death Overview Panel (CDOP) Annual Report

Barking and Dagenham Child Death Overview Panel (CDOP) Annual Report

Barking and Dagenham Child Death Overview Panel

Annual Report 2012-2013

Contents

Introduction……………………………………………………………………………..3

Terms of Reference

Organisation and resourcing of Child Death Overview Panel ……………….3

North East London (seven borough) Child Death Overview Panel Meetings 3

The Coronial Service ………………………………………………………………4

Core membership …………………………………………………………………4

Definition of child death categories ….………………………………………….5

Demographic Profile ………………………………………………………………….5

Overview of notified cases……………………………………………………………6

Number of deaths in Barking and Dagenham …………………………………6

Child deaths received by quarter …………………………………………………6

Unexpected deaths ………………………………………………………………..7

Breakdown according to age………………………………………………………7

Ethnicity Breakdown…………………………………………………………….....8

Sudden Unexpected Deaths in Infancy (SUDI) …………………………….....8

Commentary of cases reviewed ……………………...... ………….8

Number of meetings held ………………………………………………………...8

Number of reviews completed …………………………………………………...9

Neonatal deaths ……………………………………………………………………10

Sudden Unexpected Deaths in Infancy ………………………………………….10

Unexpected deaths …………………………………………………………………11

Expected deaths ………………………………………………………………...….11

Time between the child’s death and completing the review ………………...….11

Modifiable Factors and Recommendations……………………………………...... 12

Actions taken following the reviews of child deaths ..…………………………….....12

Achievements 2011-12 …………………………………………………………..……13

Future work 2012-13 …………………………………………………………………... 14
Appendix 1 – Modifiable Factors to child death reviews 2012-13 .………………... 15

  1. Introduction to Child Death Overview Panel
  2. Terms of Reference

Through a comprehensive and multi agency review of child deaths, the Child Death Overview Panel (CDOP) aims to understand how and why children die in Barking and Dagenham and use the findings to take action to reduce the risks of future child deaths and to improve the health and safety of the children in the area.

Regulation 6 of the Local Safeguarding Children Boards Regulations 2006, set out the function of the Local Safeguarding Children Board (LSCB) in relation to child deaths, made under section 14(2) of the Children Act 2004. The LSCB is responsible for:

  1. collecting and analysing information about each death with a view to identifying—

(i) any case giving rise to the need for a review mentioned in regulation 5(1)(e);

(ii) any matters of concern affecting the safety and welfare of children in the area of the authority;

(iii) any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area; and

  1. establishing procedures for ensuring that there is a coordinated response by the authority, their Board partners and other relevant persons to an unexpected death.

Barking and Dagenham CDOP is asked to categorise the likely cause of death, recorded the event that caused the death and any modifiable factors.[1]

1.2. Organisation and resourcing of CDOP
As of April 2013, the management of the CDOP Manager transitioned from the NHS to the Council and is jointly funded by the NHS Barking and Dagenham Clinical Commissioning Group (NHSBD CCG) and London Borough of Barking and Dagenham (LBBD).

1.3 North East London (seven borough) CDOP Meetings
Barking and Dagenham is a member of the seven borough north east London CDOP meeting that has been developed to share learning, agree a minimum data set so statistical analysis of trends, emerging themes and common modifiable factors can be better understood and share and learn from actions undertaken in response to emerging themes and modifiable factors. The seven boroughs consist of Barking and Dagenham, Havering, Redbridge, Waltham Forest, Hackney and the City, Newham and Tower Hamlets.

1.4 The Coronial Service
Barking and Dagenham is working closely with Waltham Forest Coroner’s Court to better develop the process to obtain full post mortems so that reviews are thorough and timely.
On 25 July 2013, a new code of standards[2] was issued aimed at speeding up inquests into deaths. It is anticipated that most inquests in England and Wales will be completed within six months. This follows complaints that bereaved families have had to wait years for a hearing.

1.5 Core Membership

The position of chair has been taken over by Matthew Cole, Joint Director of Public Health.

We have also welcomed Sue Newton, Designated Nurse Safeguarding and Dr Mahima Ruprasinghe, as Interim Designated Paediatrician for child deaths.

The full membership is made up of:

Matthew Cole / Joint Director of Public Health and CDOP Chair
Roselyn Blackman / CDOP Manager, LBBD
Dr Mahima Rupasinghe / Interim Designated Paediatrician for Unexpected Deaths in Childhood, NHSBD
Sue Newton / Designated Nurse Safeguarding, NHSBD CCG
Avraamis Avraam / Group Manager for Safeguarding, Quality and Reviews representing Barking and Dagenham Safeguarding Children’s Board
Chris Martin / Divisional Director for Complex Needs and Social Care, Children’s Directorate, LBBD
Kevin Jeffery / Detective Inspector, Child Abuse Investigation Team, Metropolitan Police Service
Claire Butler / Children’s Safeguarding Barking Havering Redbidge Univerisity Hospitals NHS Trust
Dr Junaid Solebo / Consultant Paediatrician Named Doctor for Safeguarding Children & Young Adults. Barking Havering Redbridge University Hospitals NHS Trust
Dr Richard Burack / Named GP NHSBD

Other members are co-opted as and when necessary, to provide expert opinion and to contribute to the discussion of certain deaths.

1.6 Definitions of child death categories
The following definitions are the areas CDOP will provide commentary on reviewed cases in this report.

  • Neonatal death - is a death of a live born infant within the first 28 days of life.
  • Sudden Unexpected Death in Infancy (SUDI) – is marked by the sudden death of an infant, under 2 years old. The death is unexpected by history and remains unexplained after a thorough forensic autopsy and detailed death scene investigation.
    Sudden unexpected, unexplained death – where the pathological diagnosis is either SIDS or ‘unascertained’ at any age.
  • Unexpected Death - is a death of an infant or child (less than 18 years old) which:

Was not anticipated as a significant possibility for example, 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]

  • Expected Death - an expected death is defined as one where the patient's demise is anticipated in the near future and plans have been put in place and the cause of death is known. There are no suspicious circumstances to suggest that anything untoward has occurred and the decision that death is expected will be clearly documented in clinical notes. This will be separate from a "do not resuscitate order".

2 Demographic Profile
In the 2011 Census, the population of Barking and Dagenham was recorded as 185,911, with a total of 53,544 children aged 0-18 years. This represents 28.8% of the population. Table 1 on the next page gives a breakdown of the total children and shows the number and percentage increase according to age.

There has been a significant percentage increase of 48.91% in 0-4 year olds.
Table 1

Total number of children by age and increase by number and percentage
2011 / 2001 / Number increase/ decrease / % increase / decrease
All People / 185,911 / 163,944 / 21,967 / 13.40%
0-4 / 18,676 / 12,542 / 6,134 / 48.91%
5-7 / 8,989 / 7,479 / 1,510 / 20.19%
8-9 / 5,342 / 4,984 / 358 / 7.18%
10-14 / 12,757 / 11,107 / 1,650 / 14.86%
15 / 2,534 / 2,242 / 292 / 13.02%
16-17 / 5,246 / 4,441 / 805 / 18.13%

The ethnic mix has changed since the 2001 census. The White British group fell from 82.5% of the total population to 50.5%, compared to increases in Black African (from 4.4% to 15.4%) and White other groups (from 2.6% to 7.8%). Asian and other ethnic groups are now estimated at 17.5%, compared to 6% in 2001.[5]

  1. Overview of Notified Cases
    Deaths that have been notified to the Barking and Dagenham CDOP are not all reviewed and closed during the same year of notification. The Department of Education recognise it may take a number of months (or years in some cases) to gather sufficient information to be able to fully review a child’s death. This can be due to criminal proceedings, autopsies, coroners’ reports, serious incidents (SIs) and serious case reviews (SCRs). Barking and Dagenham CDOP will await the conclusion of these investigations before a review is undertaken.

Table 2 / 2008-09 / 2009-10 / 2010-11 / 2011-12 / 2012-13
BD / 32 / 24 / 19 / 27 / 24

3.1 Number of deaths in Barking and Dagenham notified to the CDOP
In 2012-13, there were 24 child deaths reported to the CDOP. Table 2 gives a breakdown of child deaths reported to the CDOP since its establishment in 2008. This figure has fluctuated between 19 and 32 during the past five years.

3.2 Child death notifications received by quarter
Table 3 below shows this year is the first time since the establishment of CDOP we have seen a high number of deaths over Q2 and 3. In previous years Q3 has returned the highest number of child deaths.

Table 3 / 2008-09 / 2009-10 / 2010-11 / 2011-12 / 2012-13
Q1 / 4 (13%) / 6 (25%) / 3 (16%) / 7 (26%) / 4
Q2 / 8 (25%) / 3 (12%) / 5 (26%) / 5 (18.5%) / 8
Q3 / 11 (34%) / 10 (42%) / 6 (32%) / 10 (37%) / 8
Q4 / 9 (28%) / 5 (21%) / 5 (26%) / 5 (18.5%) / 4
Total no of child deaths / 32 (100%) / 24 (100%) / 19 (100%) / 27
(100%) / 24

3.3 Unexpected deaths
Of the 24 deaths reported to CDOP this year, there were 9 unexpected deaths. Eight rapid response meetings were held and a rapid response discussion to the one where CDOP did not hold a meeting.

3.4 Breakdown according to age.

Diagram 1 shows the breakdown of child deaths according to age of child deaths reported to CDOP during 2012-13.
The highest proportion of deaths, 46% (11), is within the neonatal period, 0-27 days. Children under 1 year of age represent 67% (16) of the total child deaths. This is consistent with previous years and with national figures.

Diagram 1

3.5 Ethnicity Breakdown

Diagram 2 shows a breakdown of child deaths reported to CDOP in 2012-13 according to ethnicity. 46% (11) of deaths were among the Black African/Caribbean/ Black British group of the resident population.

During 2013-14, the Public Health Directorate will assist the CDOP with statistical analysis of the local neonatal, infant and child mortality rates, using comparative and statistically reliable methods. This will enable the borough to gain a better understanding of any factors such as age, sex, ethnicity or location. This information will be included in the Joint Strategic Needs Assessment (JSNA) and refreshed annually.

Diagram 2

3.6 Sudden Unexpected Deaths in Infancy (SUDI)

Of the 24 deaths reported to CDOP this year, one involved Project Indigo the Metropolitan Police Service response to SUDI. Whilst the cause of death retuned by the Coroner is SUDI, the panel has not yet reviewed it to formally categorise it. See Point 6 below for further details.

4 Commentary on cases reviewed

This section will provide commentary on the cases reviewed and where modifiable factors have been identified.

4.1 Number of meetings held
CDOP developed a Pre Review Group (PRG) meeting to look at all the cases, before they are presented to the CDOP. The case is discussed and the meeting determine whether there is sufficient information; propose a category of death and consider any modifiable factors.

During 2012-13 CDOP met six times. The PRG also met in excess of six times to fully consider the cases and any potential concerns. These increased number of meetings were paramount to reviewing 46 cases that included six cases from 2010-11 and 27 cases from 2011-12.
At 31 March 2013, there were 10 child death reviews that were ongoing.

4.2 Number of reviews completed

46 child death reviews were completed by CDOP in 2012-13. This is significantly higher than the reviews completed in previous years.

Table 4 gives a breakdown of the child deaths that were reviewed and the year the child died.
Table 4

Number of child deaths that occurred between 1 April 2010-11 / Number of child deaths that occurred between 1 April 2011-12 / Number of child deaths that occurred between 1 April 2012-13
6 / 27 / 13

Of the 46 child death reviews completed, 18 were identified as having modifiable factors.

CDOP categorised the likely cause of death and recorded the event that caused the death.

Table 5 below shows the highest number of deaths was among the perinatal/neonatal event with 11 (24%). These deaths were largely due to prematurity with 6 identified as having modifiable factors. 8 (17%) were among the trauma and other external factors. These included Road Traffic Accidents, Fire and Choking. The three where insufficient information has been categorised, these were due to deaths that occurred abroad. 8(17%) were among the chromosomal, genetic and congenital anomalies and no modifiable factors were identified.

Table 5

Number of child deaths with modifiable factors recorded under this category of deaths / Number of child deaths with no modifiable factors recorded under this category of deaths / Number of child deaths where there was insufficient information to assess if there were modifiable factors
Trauma and other external factors / 3 / 2 / 3
Malignancy / 6
Acute medical or surgical condition / 3
Chronic medical condition / 1
Chromosomal, genetic and congenital anomalies / 8
Perinatal/neonatal event / 6 / 5
Infection / 3 / 2
Sudden unexpected, unexplained death / 3 / 1
Unknown category
TOTAL / 18 / 25 / 3

Table 6 shows a breakdown of the child deaths identified as having modifiable factors and the year the child died.

Table 6

Number of child deaths with modifiable factors that occurred between 1 April 2010-11 / Number of child deaths with modifiable factors that occurred between 1 April 2011-12 / Number of child deaths with modifiable factors that occurred between 1 April 2012-13
5 / 11 / 2

Tables 7 and 8 show the categorisation of deaths where modifiable factors have been identified and the event that caused the death.
Table 7

Category / Number of child deaths with modifiable factors recorded under this category of deaths
Trauma and other external factors / 3
Acute medical or surgical condition / 3
Perinatal/neonatal event / 6
Infection / 3
Sudden unexpected, unexplained death / 3
TOTAL / 18

Table 8

Events / Number of child deaths with modifiable factors recorded under this event
Neonatal death / 6
Sudden unexpected death in infancy / 3
Road traffic accident/collision / 2
Fire and burns / 1
Infection / 3
Acute Bronchitis / 1
Epilepsy / 1
Sickle Cell Crisis / 1
TOTAL / 18

4.3 Neonatal Deaths
There were six neonatal deaths, where modifiable factors were identified (see tables 7 and 8 above). These deaths were classified as expected deaths however three Serious Incident (SI) Reports were completed by Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT). The SIs are monitored by NHSBD through their Clinical, Quality Review Meeting.

4.4 Sudden Unexpected Death in Infancy (SUDIs)
There were four SUDIs reviewed by CDOP. Three were identified as having modifiable factors. The issues identified were inappropriate feeding in a car seat by the road side; no follow-up care plan for child with significant haemolytic disease with attending risk of anaemia and prolonged jaundice; anti-viral treatment should have commenced earlier as precautionary to herpes simplex.

4.5 Unexpected deaths
Of the 46 child death reviews, 20 (43%) were classified as unexpected deaths.
Table 9 gives a breakdown of the unexpected deaths according to the events classified by CDOP. 12 were identified as having modifiable factors.

Table 9

Unexpected Deaths
Number of child deaths with modifiable factors recorded under this event / Number of child deaths with no modifiable factors recorded under this event / Number of child deaths where there was insufficient information to assess if there were modifiable factors
Known life limiting condition / 1
Sudden unexpected death in infancy / 3 / 1
Road traffic accident/collision / 2 / 1 / 1
Fire and burns / 1 / 2
Other non-intentional injury/accident/trauma / 1
infection / 3
Epilepsy / 1
Sickle Cell Crisis / 1
Acute Bronchitis / 1
TOTAL

4.6 Expected Deaths
Of the 46 reviews carried out, 26 related to expected deaths. 18 of these were to under 1 year olds with the majority classified as perinatal/neonatal deaths.

4.7 Time between the child’s death and completing the review

Table 10 below provides a breakdown of the child death reviews according to modifiable factors and number of months.
Data analysed by Department for Education (DfE) suggests that reviews of child deaths are likely to take longer if modifiable factors are identified. DfE says that nearly 40% of deaths where modifiable factors were identified took more than 12 months to complete.[6]

Table 10

Number of child deaths which were reviewed within the following time periods (from the date of death to the date the review was completed)
Number of child deaths with modifiable factors / Number of child deaths with no modifiable factors / Number of child deaths where there was insufficient information to assess if there were modifiable factors
Under 6 months / 9 / 1
6 or 7 months / 1 / 3
8 or 9 months / 2 / 2
10 or 11 months / 4 / 4 / 2
12 months / 1
Over one year / 11 / 6
Unknown
TOTAL / 18 / 25 / 3

5 Modifiable Factors and Recommendations to all cases reviewed between 2012-13
The modifiable factors identified relate to both unexpected and expected deaths with the majority to unexpected deaths. Recommendations were made by CDOP some arising from SIs and internal investigations. See Appendix 1 for details.

6 Actions taken following the reviews of child deaths
In 2012-13, as well as recommendations made to agencies, CDOP worked with Children's Rights, Participation & Engagement to raise awareness of fire and road safety during child safety week. CDOP also worked jointly on the safe sleep campaign to SUDIs with Havering, Redbridge and Waltham Forest.

Project Indigo’s Draft SUDI – Analytical Report 2013[7] states that Barking and Dagenham is among the priority boroughs as BD contribute to 48% of all SUDIs in London since 2005. In the East region, 61% of SUDIs occur in Barking and Dagenham, Hackney and Newham combined.

Table 11 on the next page gives a breakdown of SUDIs in BD from 2005 to 2012[8]. The figures show on average two SUDIs a year. The SUDI recorded in 2012 has not yet been reviewed by the Panel.

Table 11

SUDIs from 2005-2012
SUDI
2005 / 2
2006 / 4
2007 / 2
2008
2009 / 4
2010
2011 / 4
2012 / 1
Total / 17

Safe sleeping (including co-sleeping) continue to be a concern to panels, according to DfE[9]. Other areas of concern are: language barriers and access to health services especially emergency services; consanguinity, bereavement support to include support offered to children following the death of a parent, carer or sibling; smoking and road safety.
The majority of these concerns are being discussed by the north east London seven borough CDOP. Redbridge and Waltham Forest have carried out some work relating to consanguinity. Although, this is not currently an identified theme in BD, Redbridge and Waltham Forest will share their findings with us at the next seven borough meeting in September 2013.

7 Achievements

  • Developing the effectiveness and quality of the work of CDOP by increasing the number of regular meetings and to include a Development Day within the yearly planner.
  • Reviewing and closing a high number of open cases.
  • Revising the Terms of Reference to incorporate the roles and responsibilities of all panel members
  • Working collaboratively with the 7 borough CDOPs within north east London to share best practices and learning.
  • Involving bereaved parents and family members into the CDOP process by inviting them to contribute to the process.

8 Future Work Plan 2013-14