Annual Report 2014 -15

Charts

Chart 1: / Infant Mortality and Deprivation (Public Health Outcomes Framework 2015)
Chart 2: / Injuries to Children and Young People
Chart 3: / Infant Mortality Rates, Norfolk, 2001-2012 compared to East of England
Chart 4: / Infant Mortality Rates per 1000, East of England Upper Tier Authorities 2011-13
Chart 5: / Child Deaths in 2014-15, Age at Death
Chart 6: / Child Deaths in 2014-15, Place of Residence
Chart 7: / Cases Closed by CDOP in 2014-15, Age of Child at Time of Death
Chart 8: / Cases Closed by CDOP in 2014-15, Causes of Death

Norfolk Child Death Overview Panel Annual Report 2014-15

  1. Introduction

1.1The purpose of the panel

Child DeathOverviewPanels(CDOPs) wereestablishedthroughoutEngland,underthedirectionofWorking Together to Safeguard Children,2006.The Guidance on the Panels has since been amended on several occasions, most recently March 2015.

Although the death of a child is fortunately rare, each case is a tragedy and it is important to understand whether anything could have been done to prevent it or to have made it less likely.

It is also important to ensure that services are performing as well as they can be and to recognise any emerging trends in causes of death that can be addressed to prevent future cases. Fortunately numbers are so small that it is important to base any trend view on accurate analysis over time.

The functions of CDOP are:

  • reviewing all child deaths, excluding those babies who are stillborn and planned terminations of pregnancy carried out within the law;
  • collecting and collating information on each child and seeking relevant information from professionals and, where appropriate, family members;
  • discussing each child's case, and providing relevant information or any specific actions related to individual families to those professionals who are involved directly with the family so that they, in turn, can convey this information in a sensitive manner to the family;
  • determining whether the death was deemed preventable, that is, those deaths in which modifiable factors may have contributed to the death and decide what, if any, actions could be taken to prevent future such deaths;
  • making recommendations to the LSCB or other relevant bodies promptly so that action can be taken to prevent future such deaths where possible;
  • identifying patterns or trends in local data and reporting these to the LSCB;
  • where a suspicion arises that neglect or abuse may have been a factor in the child's death, referring a case back to the LSCB Chair for consideration of whether an Serious Case Review is required;
  • agreeing local procedures for responding to unexpected deaths of children; and
  • Co-operating with regional and national initiatives - for example, with the National Clinical Outcome Review Programme - to identify lessons on the prevention of child deaths.

In reviewing the death of each child, the CDOP considers modifiable factors, for example, in the family environment, parenting capacity or service provision, and considers what action could be taken locally and what action could be taken at a regional or national level. (Working Together to Safeguard Children 2015). This approach is based on the presumption that CDOP is intended to assist and develop learning across the system.

The Reportcoversthe period April 1st2014to 31stMarch 2015.

1.2The constitution of the Norfolk Child Death Overview Panel (CDOP)

NorfolkCDOP isasubcommittee oftheNorfolkSafeguardingChildrenBoard(NSCB).ThepanelincludesrepresentativesfromtheNSCB,Health Services and Public Health,Children’sServices,theNorfolkConstabulary, EastAnglianChildren’sHospicesanda lay member.FromSeptember 2014 to March 2015 the panel was chaired by the Interim Director of Public Health. Membershipof thepanel is appended atAppendix1.

Thepanel’s Terms of Reference(Appendix2)outline itsconstitution,functions,workingarrangements,reportingandaccountability.

  1. The National Picture

A Report in 2014 for the Royal College of Paediatrics and Child Health, the British Association for Child and Adolescent Public Health and the National Children’s Bureau found that 60% of child deaths in the UK occurred before the age of one year and that 70% of these were within the first 28 days of life. The mortality rate in all age groups was higher for boys than for girls.

Although infant, child and adolescent death rates in the UK have declined substantially and continue to fall, overall the England and Wales’schildhood mortality rate is higher than in some other European countries. This disparity is particularly the case for infant deaths and deaths among children and young people who have chronic conditions. The neonatal mortality rate at the time of the study exceeded that in all the Scandinavian countries and a number of other European countries including not only France and Germany, but other less affluent countries such as Portugal, Ireland and the Czech Republic.The Report suggested that in some cases lives in the UK could be saved by improvements in care by health services.

Key contributing factors to neonatal and infant deaths were identified as low birth weight and preterm birth, that is, birth before 37 weeks gestation. Smoking in pregnancy and socio economic deprivation were also important and often inter-related factors. Sudden unexplained death in infancy is higher in the UK in comparison to other high income countries and is more likely in economically deprived families, among those who smoke and where the mother is very young. (Why children die: death in infants, children, and young people in the UK - Part A, May 2014,A Report by:Ingrid Wolfe, Alison Macfarlane, Angela Donkin, Michael Marmot and Russell Viner on Behalf of: Royal College of Paediatrics And Child Health National Children’s Bureau British Association for Child and Adolescent Public Health)

The Public Health Outcomes Framework (Public Health England 2015) also shows a clear correlation between infant mortality and socio-economic deprivation. In Norfolk around 90,000 people live in areas which are considered to be among the most and the second most deprived in the country and the birth rate is higher in these areas than in the rest of Norfolk.

Chart 1: Infant Mortality and Deprivation (Public Health Outcomes Framework 2015)

The 2014 Report found that for children aged between 1-4 and 5-10 years old injuries and poisonings, cancer and congenital causes are the most frequent causes of death in children. From 10-19 injuries and poisonings and cancers remain the lead causes, but with a sharp increase in the proportion of injuries and poisonings in the 15-19 age group. The authors stressed that many of the causes and determinants of childhood deaths are preventable.

In this context it should be noted that the rates of hospital admissions for injuries and poisonings in Norfolkare the worst in the Region for 0-4 and 0-14 year olds. Both rates are significantly above the national average and appear to be rising. Rates are particularly high in Kings Lynn and West Norfolk and in Norwich

Chart 2: Injuries to Children and Young People (Data from the PH Outcomes Framework 2015)

  1. Regional Comparison

The available data is for infant mortality and for comparative purposes this is generally given as the rate of deaths under the age of 1 year per 1000 live births over a rolling three year period.

The most recent figures for the period 2011-13 show that while the Norfolk rate is around the national average, it appears to be rising and has climbed above the regional average. This may be a feature of the small numbers involved, but it is a matter for concern and requires further investigation and observation.

Chart 3: Infant Mortality Rates per 1000, Norfolk, 2001-2012 compared to East of England (PH Outcomes Framework 2015)

Chart 4: Infant Mortality Rates per 1000, East of England Upper Tier Authorities 2011-13 (PH Outcomes Framework 2015)

  1. Overview of child deaths in Norfolk in 2014-15

4.1Age and Gender

Fifty seven Norfolk children died in 2014-15, thirty five boys (61%) and twenty two girls (39%). Thirty seven of these children (65%) were under the age of one and twenty one, 57% of the total number under the age of one, were less than 28 days old.

Compared to the national figures above, this suggests a higher than average percentage of deaths in the age group between twenty eight days and one year old, however, it is difficult to generalise from small numbers.

Chart 5: Child Deaths in 2014-15, Age at Death

4.2Place of Residence

Of the fifty seven deaths in the year, forty two of the children were from the four districts of Breckland, Broadland, Kings Lynn and West Norfolk with the remaining fourteen being from North Norfolk, Great Yarmouth and South Norfolk. In one case the place of residence was not recorded.

Chart 6: Child Deaths in 2014-15, Place of Residence

4.3Cases reviewed by the Panel in 2014-15

The Panel reviewed forty eight cases during the year, but only had sufficient information to make a decision on thirty two of these, seventeen boys and fifteen girls. The cases reviewed did not all relate to deaths within the year 2014-15, some having occurred in previous years. Thepanel only considerscases whensufficient information isavailable foraconclusiontobe reached and in someinstances,significant time mayelapsebeforetheCDOP isina positionto review a case.

In the previous year, 2013 -14, less than half the cases reviewed were completed and this, combined with the cancellation of five Panels in 2014-15, led to a considerable time delay in the review and closure of cases.

None of the cases reviewed in 2014-15 was on a child protection plan or had any known safeguarding issues.

Insufficient information on ethnicity was recorded to enable an analysis to be undertaken.

Most of the deaths reviewed were of very young children, with twenty cases of the thirty two being children younger than one year of age.

Chart 7: Cases Closed by CDOP in 2014-15, Age of Child at Time of Death

By comparison with the previous year the Panel reviewed more cases of sudden unexplained deaths, congenital anomalies and malignancy. This is not necessarily a reflection of the prevalence of these issues, but of the grouping of cases within the review process.

Chart 8: Cases Closed by CDOP in 2014-15, Causes of Death

Of the thirty two cases reviewed, the Panel agreed that one was preventable and two others were potentially preventable. No modifiable factors were found for twenty seven of the remainder and in two cases there was insufficient information for the Panel to form a view.

  1. Issues arising from the Panel Reviews

A number of key themes emerged from the reviews undertaken by CDOP and these will be taken forward into the work of the group in 15/16 to inform future priorities. This is particularly important given the fact that there are clear principles for reviewing child deaths set out in the regulatory framework in which CDOP operates

  • Every child death is a tragedy
  • To learn the lessons to prevent future child deaths
  • To undertake a joint agency approach to reviews
  • To take positive action to promote the welfare of local children

The emerging themes are

  1. Sudden Unexplained Death

The Panel reviewed five cases of sudden and unexpected death in infants. A number of key issues emerged

  • Co-sleeping,
  • parental alcohol use
  • smoking emerged
  • The nature and suitability of accommodation.

It appears that despite safer sleeping campaigns and awareness raising the messages are not being heard.

The Panel was also concerned that charges for cots in holiday accommodation would encourage co-sleeping. This has been raised with colleagues in trading standards who have regular contact with many holiday accommodation providers.

In at least one case inappropriate living accommodation was an issue.

  1. Childhood Obesity

Following a child death in a previous year the Panel developed a policy on obesity as a safeguarding issue. This was approved by the LSCB in 2014. This needs to link to the work undertaken within public health and across the partnership to promote healthy lifestyles amongst young people and their families.

  1. Young People’s Mental Health, Suicide and Self Harm

Concerns have been raised at a number of Panels concerning the extent of inter-relationship between self-harm, suicide and accidental death. An analysis was undertaken by Public Health of hospital admissions relating to self-harm and a separate review led by the Critical Incident Co-ordinator of recent suicides in young people. There is a local perception that there may be a link between self-harm and bereavement, but this has not yet been fully researched.

The child suicide review group has been established across the multi-agency partnership to consider some of the issues that have arisen, and is working to consider trend information to inform future consideration by CDOP.

Future priorities.

The priorities for 15-16 will focus on a number of key activities

  • Further developing and strengthening the role of CDOP , to improve the operating processes for reviewing child deaths,to make systems for data collection more efficient and timely and to ensure cross agency engagement at the appropriate level
  • To develop a future plan to address the issues highlighted in this report including those identified at 6.1 to 6.3, which will include a forward plan for CDOP and a communication strategy

1