Document Author / Sue Gower
Document Owner
© / Kent Safeguarding Children Board ©
Sessions House
County Road, Maidstone. Kent. ME14 1XQ
Email:
Summary of Purpose / The requirement for LSCBs to review all child deaths became a statutory requirement from 1st April 2008. The process is outlined in Working Together to Safeguard Children 2013. In Kent this review process has been the Child Death Overview Panel (CDOP). This document provides an analysis of the deaths that occurred April 2013- March 2014.
Accessibility / This document can be made available in large print, or in electronic format.
There are no copies currently available in other languages
How this document was created / Draft 1 / Document created by SG
Draft 2 / Review by Chair
Draft 3 / Ratification by CDOP Panel
Draft 4 / Sign off by Business Group and Board
Equalities Impact Assessment / During the preparation of this policy and when considering the roles & responsibilities of all agencies, organisations and staff involved, care has been taken to promote fairness, equality and diversity in the services delivered regardless of disability, ethnic origin, race, gender, age, religious belief or sexual orientation. These issues have been addressed in the policy by the application of an impact assessment checklist.
Circulation Restrictions
Version / Detail of change / Date
1.0 / Andrew Scott-Clark / July 2014
2.0 / Sue Gower / July 14
3.0
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Contents
Number / Section / PageForeword / 4
Introduction / 5
Scope of Reviews and Common Terminology / 6
The process following the death of a child / 7
Child Death Review Process / 8
Statistics – Reported Cases / 9
Statistics – Reviews carried out by CDOP / 11
Time Taken to Complete Reviews / 12
Modifiable Factors / 13
Serious Case Reviews / 14
Achievements / 15
12. / Learning Points / 15
13. / Training / 15
Appendix A – Definition of Child Death Terms / 16
Appendix B – Definitions of categories as required by the Department for Education and used by CDOP / 17
Appendix C – Membership of the CDOP / 18
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1.Foreword
This year has seen a number of changes in personnel within the core CDOP team. Having served as Chair of the Kent CDOP Panel for a number of years, Meradin Peachey left in March 2014 to take up the position of Tri-Borough Director of Public Health for Hammersmith and Fulham, Kensington and Chelsea and Westminster.I assumed this responsibility in my role as Interim Director of Public Health in March 2014. Sue Gower, KSCB Programme Development Officer came into post in August 2013 and is now the KSCB officer with responsibility for CDOP replacing Lesley Burnand. Sue Gibbons was appointed by KCHT as Specialist Nurse, Child Death, taking over the role formerly held by Dawn Bissett.
Improvements to local CDOP processes continue to take place and in order to expedite cases, specific meetings are now held to consider neonatal and SUDI (Sudden Unexpectedly Death in Infancy) cases respectively. In this way, the Panel is able to review and ‘sign’ these off thesecases as quickly as possible. As a result of work detailed in last year’s Annual Report, communications between local settings and specialist hospitals in London who share the care of children in Kent have improved and the safe sleeping campaign that commenced at the end of the 2012-13 reporting period has been reviewed and revised.
Any child death is a tragedy, and I am grateful to members of the CDOP panel for their commitment to this process and the respect that is shown for the children, young people and families concerned at each meeting.
Andrew Scott-Clark
Chair of the Child Death Overview Panel
2. Introduction
This is the fifth annual report of the Child Death Overview Panel (CDOP) in Kent. The Panel was established on 1st April 2008 in line with Government guidance outlined in ‘Working Together to Safeguard Children’ (HM Government 2006 and updated in 2010 and 2013). The guidance states that all child deaths (excluding stillbirths and planned terminations of pregnancy carried out within the law) up to the age of 18 should be monitored and places the expectation on Local Safeguarding Children Boards (LSCB) that they will:
- Collect and analyse information about each death;
- Put in place procedures for ensuring that there is a co-ordinated response to an unexpected death.
The process of responding to a child death is set out in Chapter 5 of HM Government’s statutory guidance:‘Working Together to Safeguard Children’ March 2013. Itsets out both the method in which a child death should be investigated by the agencies to establish how a child died and the subsequent review process. The review is in addition to any investigation carried out on behalf of the coroner. The Child Death Overview Panel will also examine those deaths where there has been no coronial involvement.
The key purpose of reviewing all child deaths is to identify learning and any modifiable factors that canbe addressed by further consideration. These findings are shared with the DfE who take a national overview of the issues.The detailed guidance on how a child death should be investigated in Kent can be found in the Unexpected Death of a Child Procedures (May 2013).The detailed procedure for reviewing the death of a child is set out in the Child Death Overview Procedures and Practice Guidance (May 2013). Both of these policies can be found at They can also be found online in the Kent and Medway Safeguarding Children Procedures: 2.5.3 Child Death Reviews.
3.Scope of reviews and Common Terminology
The Child Death Overview Panel has the responsibility to review the death of all children who are resident within KSCB's geographical area from birth up to the age of 18 years.
Common Terms relating to Infant Death
4.The Process following the death of a child
Definition of Unexpected Death
The death of an infant or child (less than 18 years) 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.
5.Child Death Review Process
All child deaths must be reported to KSCB by the relevant agency within 24 hours.
Agencies who knew the child are then formally asked to provide any known informationabout the child, their family, their environment and services provided. This information is collated between 4 and 8 weeks after the death, following which it is then reviewed by the Child Death Overview Panel(CDOP) which meets monthly. The CDOP is made up of representatives from health (paediatricians and nurses), police, education, children’s social services, Foundation for Study of Infant Deaths, ambulance service and the KSCB, (Appendix B details members). Other specialists are invited to attend specific meetings when their expertise is required e.g. neonatologist, Police Serious Crash Investigator.
The CDOP are required to categorise every death using the framework below, and to identify any modifiable factorsi.e. actions that could be altered. These are discussed and recommendations made in order to raise awareness of any issues and to prevent future deaths. Gaps in service provision both prior to the death and afterwards, such as bereavement support are also identified and any public health issues considered.
- Deliberately inflicted injury, abuse or neglect
- Suicide or deliberate self-inflicted harm
- Trauma and other external factors
- Malignancy
- Acute medical or surgical condition
- Chronic medical condition
- Chromosomal, genetic and congenital anomalies
- Perinatal/neonatal event
- Infection
- Sudden unexpected, unexplained death
6.Statistics - Reported Cases
The following statistics have been compiled from data received by KSCB from partner agencies throughout the year in question.
a.Number of Deaths for 2013/2014, highlighting Unexpected Deaths
Although the number of deaths was consistent in the reporting years 2009-10, 2010-11 and 2011-12, there has been a decrease in numbers in the current reporting period. The numbers of unexpected deaths rose during the 5 reporting periods in question but have decreased in 2013-14. The numbers of deaths are shown below:
Number of deaths / Number of unexpected deaths2009/10 / 94 / 35
2010/11 / 94 / 41
2011/12 / 94 / 40
2012/13 / 99 / 52
2013/14 / 63 / 34
b.Number of Deaths by Age
The largest number of deaths by age consistently falls within the neonatal group, with the lowest number of deaths between the ages of 5 and 9. The breakdown of data by age is shown below:
2009/10 / 2010/11 / 2011/12 / 2012/13 / 2013/140-28 days / 31 / 39 / 42 / 48 / 25
29-365 days / 25 / 27 / 12 / 20 / 16
1-4 years / 11 / 6 / 12 / 8 / 9
5-9 years / 7 / 9 / 5 / 7 / 5
10-14 years / 7 / 6 / 11 / <5 / 5
15-18 years / 13 / 5 / 12 / 11 / 3
unknown / 0 / 0 / 0 / 0 / 0
c.Number of deaths by gender
Kent data consistently identifies more deaths of male children than female, detailed below:
2009/10 / 2010/11 / 2011/12 / 2012/2013 / 2013/14Female / 43 / 41 / 40 / 42 / 28
Male / 51 / 51 / 52 / 56 / 35
7.Statistics – Reviews carried out by CDOP 2013/14
During 2013/14 the CDOP met 10 times and completed the reviews of a total of 91 cases.
The difference between this data and the total number of deaths notified within the year is often due to an inherent backlog in the gathering of information and waiting for the completion of Post Mortems, Inquests or Criminal Proceedings. Over the three year period the number of deaths which had taken 6 months or longer to review and complete peaked during 2009/10 and is gradually being reduced from this point.
The data in the above chart relates to deaths where the review has been completed by the CDOP each year. The panel have reviewed 310 deaths in four years.
8.Time taken to complete reviews 2013-14
The data in the above chart relates to the time taken between the date of death and when the review has been carried out. The target is for the review to take place between 3 and 6 months. The timescales of data collection and time taken to review cases has been improving significantly over the past year. Most delays of more than 6 months relate to waiting for inquests to be completed or criminal proceedings. There are also delays in reviewing some cases, as Kent groups the types of deaths into themed meetings and invite experts in particular areas in order to assist with these reviews. However the streamlining of Kent’s procedures will continue to see improvements in the time taken to review cases.
The Child Death Overview Panel will take into consideration every known factor relating to the child, the family, home circumstances, parenting capacity and service provision—in particular to identify where there are gaps. The Panel is then required to categorize the primary cause of the death. The definition for each category is shown in Appendix B.
Category of Death2011/12 / 2012/13 / 2013/14
Deliberately inflicted injury, abuse or neglect / 0 / <5 / <5
Suicide or deliberate self-inflicted harm / <5 / <5 / <5
Trauma and other external factors / 5 / 5 / 7
Malignancy / 9 / 12 / 6
Acute medical or surgical condition / 0 / 5 / <5
Chronic medical condition / <5 / 14 / <5
Chromosomal, genetic and congenital anomalies / 7 / 5 / 11
Perinatal/neonatal event / 20 / 25 / 22
Infection / <5 / <5 / <5
Sudden unexpected, unexplained death / <5 / 12 / 13
9.Modifiable Factors Identified 2013-14
The CDOP consider whether there are any modifiable factors which, if addressed, may prevent similar deaths in the future. It also seeks to identify:
- any lessons to be learned from the death,
- patterns/similar deaths in the area.
Of the 91cases reviewed there were 15 (18% of total reviewed deaths) which were identified as having modifiable factors. These factors include:
•Supervision in the bath
•Smoking x 3
•Inappropriate sleeping arrangements for infants
•Appropriate parental access to medical help
•Road safety and safety markings
•Cycle helmets and lights
•Inexperienced drivers/seat belts/road safety
•Co-sleeping x 3
•Room temperature x 3
•Alcohol/Substance misuse
•Transfer of new born infant
•Delay in Caesarean procedure.
10.Serious Case Reviews (SCRs)
Local Safeguarding Children Boards (LSCB’s) are required to undertake Serious Case Reviews when a child dies and neglect or abuse is known or suspected. The requirements for Serious Case Reviews are set out in Chapter 7 of ‘Working Together to Safeguard Children’ 2013.
The KSCB Serious Case Review Panel determine whether a Serious Case Review should be commissioned, either as part of the statutory requirement or where it is felt that the resulting information will inform practice.No new SCRs were commissioned in 2013/14.
Copies of all Executive Summaries arising from Serious Case Reviews and management reviews undertaken by the Kent Safeguarding Children Board are published on the Board’s website:
11.Achievements
The CDOP has considered more cases this year and has improved the quality of information and learning points that result from the meetings.
12.Learning Points
The following learning points have been identified during the period of this report:
- Education of parents to provide supervision of child at bath time – a ‘safe bathing’ message.
- The need for timely transfer of neurosurgical children.
- Reduction in smoking in pregnancy.
- The impact of an adult’s condition (alcohol or substance misuse or mental health issues) can have on children and young people in the family.
- The use of bedding rather than duvets in a cot and an understanding of the correct room temperature for a baby
- The need to continue with ‘stop smoking’ activity before, during and after pregnancy.
- The need to reduce co-sleeping
13.Training
During 2013-14,a total of 50 practitioners attended four training sessions relating to the Child Death Review Process. In addition, joint training is now carried out in partnership with Kent Police as part of SCAIDP.
APPENDIX A
Child Death Terms
Neonatal: The death of an infant from any time after birth until the age of 28 days.
Infant death: The death of any infant up to a year.
Pre-viable neonatal death: For the purpose of CDOP review, a pre-viable neonatal death is any infant who was born below 24 weeks gestation with signs of life.
Sudden Unexpected Death in Infancy (SUDI): (Descriptive term) The sudden unexpecteddeath of an infant under one year of age.
Sudden Infant Death Syndrome (SIDS)(Willinger et al 1991) The cause of death of an infant <1 year cannot be explained despite a full history, multi-agency investigation physical examination, and paediatric post mortem findings performed to a standardised protocol.
Unexpected deaths: The 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.
Expected deaths: All other deaths, for example those due to lethal genetic abnormalities, cancer, neurodegenerative conditions, etc. It should be noted that some children with these conditions may die unexpectedly and such deaths may need to be assessed sensitively by the Rapid Response Team. For information on the Rapid Response process, see KSCB Procedures at
Modifiable factors: One or more factors, which may have contributed to the death of the child and which, by means of locally or nationally achievable interventions, could be modified to reduce the risk of future child deaths.
APPENDIX B
Department for Education CDOP Categories
1. Deliberately inflicted injury, abuse or neglectThis includes suffocation, shaking injury, knifing, shooting, poisoning & other means of probable or definite homicide; also deaths from war, terrorism or other mass violence; includes severe neglect leading to death.
2. Suicide or deliberate self-inflicted harm
This includes hanging, shooting, self-poisoning with paracetamol, death by self-asphyxia, from solvent inhalation, alcohol or drug abuse, or other form of self-harm. It will usually apply to adolescents rather than younger children.
3. Trauma and other external factors
This includes isolated head injury, other or multiple trauma, burn injury, drowning, unintentional self-poisoning in pre-school children, anaphylaxis & other extrinsic factors. Excludes Deliberately inflected injury, abuse or neglect. (category 1).
4. Malignancy
Solid tumours, leukaemias& lymphomas, and malignant proliferative conditions such as histiocytosis, even if the final event leading to death was infection, haemorrhage etc.
5. Acute medical or surgical condition
For example, Kawasaki disease, acute nephritis, intestinal volvulus, diabetic ketoacidosis, acute asthma, intussusception, appendicitis; sudden unexpected deaths with epilepsy.
6. Chronic medical condition
For example, Crohn’s disease, liver disease, immune deficiencies, even if the final event leading to death was infection, haemorrhage etc. Includes cerebral palsy with clear post-perinatal cause.
7. Chromosomal, genetic and congenital anomalies
Trisomies, other chromosomal disorders, single gene defects, neurodegenerative disease,cystic fibrosis, and other congenital anomalies including cardiac.
8. Perinatal/neonatal event
Death ultimately related to perinatal events, egsequelae of prematurity, antepartum and intrapartum anoxia, bronchopulmonary dysplasia, post-haemorrhagic hydrocephalus, irrespective of age at death. It includes cerebral palsy without evidence of cause, and includes congenital or early-onset bacterial infection (onset in the first postnatal week).
9. Infection
Any primary infection (i.e., not a complication of one of the above categories), arising after the first postnatal week, or after discharge of a preterm baby. This would include septicaemia, pneumonia, meningitis, HIV infection etc.
10. Sudden unexpected, unexplained death
Where the pathological diagnosis is either ‘SIDS’ or ‘unascertained’, at any age. Excludes Sudden Unexpected Death in Epilepsy (category 5).
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APPENDIX C
Membership of CDOP
Name / Agency / TitleMeradin Peachey
AndrewScott-Clark / Kent Public Health Department / Kent Director of Public Health/ Chair of CDOP
Interim Director of Public Health/Chair of CDOP
Charles Unter / Maidstone & Tunbridge Wells NHS Trust / Vice Chair/ Consultant Paediatrician
Kel Arthur / CFE/ Education Services / Children’s Education Safeguarding Manager
Lesley Burnand
Sue Gower / Kent Safeguarding Children Board / KSCB Training Development Officer
KSCB Partnership Development Officer
Andy Pritchard / Kent Police / Detective Chief Inspector
Dawn Bissett/
Sue Gibbons / Kent Community Health NHS Trust / Specialist Nurse Child Death
Selwyn D’Costa / Dartford & Gravesham NHS Trust / Consultant Paediatrician & Named Doctor
Colin Green / East Kent Hospital University Foundation NHS Trust / Consultant Paediatrician & Designated Doctor for Ashford, Folkestone &Shepway
El Hussein Rfidah / East Kent Hospital University Foundation NHS Trust / Consultant Paediatrician & Designated Doctor for Child Death Review for Thanet & Dover
Amitha Sumathipala / East Kent Hospital University Foundation NHS Trust / Consultant Paediatrician & Designated Doctor for Child Death Review for Canterbury & Coastal Areas & Swale
Judith Howard / Lullaby Trust / Regional Development Officer
Jane Mitchell / South East Coast Ambulance Service / Safeguarding Children & Adults Manager
Paul Brightwell / Performance and Quality Assurance Manager (Children in Care) / KCC – FSC
Trish Stewart / Named Nurse for Safeguarding Children Assurance Lead / KCHT