PAN CHESHIRE CHILD DEATH OVERVIEW PANEL
Annual Report 2014 – 2015 & CDOP Priority Action Plan 2015-2016Contents / Page
Foreword from the Independent Chair / 2
CDOP Pan Cheshire
Executive Summary / 3
Background to the Child Death overview process / 4
CDOP Panel membership / 5
LSCB Population figures / 6
Child Death Review data April 2014 – March 2015 (overview) / 7- 9
National annual statistical data / 10-12
Child Death Data by LSCB area / 12-13
What have we achieved? / 14-15
CDOP Priority Action Plan 2015-2016 / 16-17
Appendices’
CDOP reports Quarter One, Two, Three and Four 2014 -2015 / 18
Glossary
Terms & Meanings / 19
Abbreviations / 19
Foreword
I commenced in post as independent chair of Pan Cheshire CDOP in May of this year.
It is clear that in 2014/15, the Pan Cheshire CDOP drove forward the CDOP priority action plan for the year and effectively reviewed child deaths in the region. This report details the work completed, and the progress made.
I am grateful to Caryn Cox, Director of Public Health, Cheshire West and Chester and to Sarah Johnson-Griffiths, Consultant in Public Health, Halton Council for chairing the CDOP in 2014/15 and I look forward to working with CDOP partners in progressing the priorities for 2015/16.
Hayley Frame
Independent Chair
Executive Summary
The report highlights the key data and findings of the panel.
- 48 child deaths were notified in the period April 2014 – March 2015
- 44 child deaths were reviewed and closed by the panel from April 2014 - March 2015
- The Child Death Overview Panel met on four occasions over the year
Of those deaths reviewed
- 61% of the deaths occurred before the child reached one year of age (27 deaths)
- 25% of the deaths occurred in Children aged 1year to 4 year
- 16% of the deaths occurred in Children aged 15 years to 17 years
- 65% of the deaths were male (29 deaths)
- 27% were Perinatal/Neonatal events(12 Deaths)
- 29.5% of deaths were classed as ‘unexpected’ (13 deaths)
- 13% of deaths reviewed had ‘modifiable factors’ (6 deaths).
When considering relatively rare events such as child deaths small variations in numbers can represent a large proportional difference. Therefore considering these figures together as a Pan Cheshire child death overview panel can help to establish a clearer representation of emerging trends or patterns.
1.Background to the Child Death Overview Processes
Since 1st April 2008 Local Safeguarding Children Boards (LSCBs) have held a statutory responsibility to review deaths of all children normally resident in their area. The criteria for a death to be reviewed are any instance whereby a death certificate is issued for a person aged 0 - 18 years, with the exception of babies who are stillborn and planned terminations of pregnancy. In order to carry out this function the LSCB is required to appoint a committee known as the Child Death Overview Panel (CDOP). The CDOP is then required to report to the LSCB chair, in order that any findings can be used to informplanning on how best to safeguard and promote the wellbeing of children within the local area.
The CDOP meet regularly to review all child deaths, expected and unexpected, in the local authority area.The panel has a fixed core membership and will include additional professional groups as necessary for the cases to be reviewed. The CDOP does not review child deaths until all investigations and criminal justice and inquest proceedings have been completed.
The purpose of the CDOP process is to gain insight into how and why children in the local area die, with the intention of protecting other children and helping to prevent future child deaths. This involves accurately establishing the cause of death, any emerging patterns of death and identifying any modifiable factors which may have contributed to a child’s death.
The Pan Cheshire CDOP is accountable to 4 LSCBs – Cheshire East, Cheshire West and Chester, Halton and Warrington.
- Membership of the Pan Cheshire CDOP (as per terms of reference)
Independent Chair
CDOP Coordinator
CDOP Nurse x 2
Designated Nurse for children x 2
Designated Doctor for CDOP x 3
Public Health Consultant
Police Inspector from PPU
Senior Manager for Children’s Social Care
LSCB Business Manager (representative across the 4 LSCBs)
Midwife with responsibility for CDOP (Cheshire West)
North West Ambulance Service (co-opted)
Lay member
The CDOP has given consideration to the frequency of the meetings in order to assist progress in presenting cases to the CDOP in a timely manner. The panel currently meet on a quarterly basis and for a whole day. It has been agreed that this frequency will remain to unless there was a significant number of cases to review.
- LSCB Child Population Figures
The child population estimates in each of the four LSCB areas is detailed in the following table.
LSCB area / Child population size* (0-17 years)Cheshire East / 74,998
Cheshire West Chester / 66,052
Halton / 28,105
Warrington / 44,103
Total / 213,258
*Source: ONS mid Year Population Estimates, 2012
4.Child Death Review Data April 2014 – March 2015: Overview
The Pan Cheshire CDOP met on four occasions between April 2014 and March 2015.
The total number of child deaths notified across the Pan Cheshire footprint between April 2013 and March 2014 was 48.
The total number of child deaths reviewed by the panel between April 2014 and March 2015 was 44.[1]
Deaths by gender
There is a higher mortality rate amongst male children, this reflects the data nationally. From April 2014 – March 2015 of the forty four child deaths reviewed by the CDOP, 29 were male (65%) whereas 15 were female (35%).
Ethnicity of child
From the national 2011Census data in England and Wales, 19.5% of the population were not from the White English/Welsh/Scottish/ Northern Irish/British ethnic group.
The North West data shows that 12.9% of the population were not from the White English/Welsh/Scottish/ Northern Irish/British ethnic group.
Ethnicity / Number of deathsWhite English/Welsh/Scottish/ Northern Irish/British / 34
Mixed/multiple ethnic/White/black African / 1
Mixed/multiple ethnic/White/Asian / 1
Any other black background / 1
Any other white background / 3
Not stated / 4
Expected and unexpected deaths
An expected death refers to a death that could reasonably been foreseen by clinicians for a period of at least 24 hours before it occurred. An unexpected death is then defined as the death of an infant or child which was not anticipated as a significant possiblity 24 hours before the death or, where there was was an unexpected collapse or incident precipitating the events that led to that death.Between April 2014 and March 2015, there were 31 deaths (70%) where the death was classified as ‘expected’.
Of the 31 expected deaths, the final category of death was as follows:
Acute medical or surgical condition 3
Chromosomal, genetic and congenital anomalies 12
Chronic medical condition2
Infection 2
Malignancy 4
Perinatal/neonatal event 8
Deaths reviewed by CDOP with modifiable factors
A key purpose of the CDOP review process is to identify any modifiable factors contributing to the death. Modifiable factors are defined as 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 (DfE 2014).
For the period April 2014 – March 2015 of those cases reviewed, there were six child deaths (13%) with modifiable factors. These factors including smoking during pregnancy, safe sleep arrangements, and the use of safety helmets when bike riding.
Of the six cases where modifiable factors were identified four of the children were under the age of four years; this equates to 66% of cases.
Category of death
Perinatal/Neonatal events and chromosomal, genetic and congenital anomalies were the predominant categories of deaths of children in the 2014-2015 year with a total of 24deaths (54%).
Event that led to cause of death
Over the period April 2014 to March 2015 neonatal deathsand known life limiting conditionswere the most common cause of death reported to the CDOP, this accounted for 75% of all deaths.
In addition, 7 deaths occurredin the 15 to 17 year age group; including 3 road traffic accidents and 2 suicides.
Child protection and statutory orders
There were three child deaths over the period April 2014 - March 2015reviewed by CDOP where a Child Protection Plan was in place at the time of the childs death and 3 child deaths reviewed by CDOP where a Statutory Order had been in place at the time of the childs’ death.
Place of death
During the period April 2014 – March 2015 the most common place of child death was within hospital (88%) this is shown as:-
11 Died in a Neonatal Ward
10 Died in the emergency department
6 Died in a Paediatric Ward
6 Died in a Paediatric Intensive Care Unit
2 Died in a Adult intensive Care Unit
4 Died in Other (inc. delivery suites, labour wards, transplant units etc
1 Unknown
The information reflects the greatest number within a Neonatal Unit (25%) and (22%) died in a emergency department. Outside of the deaths recorded in hospital, only two children (4%) died within their home of normal residence.
- National annual statistical data
The LSCBs are required to collect a considerable amount of data following the death of every child and then submit an annual return to the Department for Education. The CDOP Co-ordinator is responsible for this function on behalf of each of the four LSCBs. The Department for Education, in turn, consolidates the returns and publishes a statistical release in July. The data can be found on the Department for Education website.
National data for 2014/15 was released in July 2015 which shows a continuation of national trends; in that the decrease in child death reviews per year is consistent with a decrease in the number of registered deaths.
With regard to the numbers of deaths, it is difficult to compare the Pan Cheshire data with national trends as the CDOP database only became operational in 2013.
An area for development for the Pan Cheshire CDOP is the timeliness of reviews. A priority for 2015/16 will be to be comparable to the national average of 32% of cases being reviewed in under 6 months as during 2014/15 Pan Cheshire CDOP reviewed 14% of cases in under 6 months. The impact of parallel processes and awaiting outstanding information from agencies are contributing factors to the timeliness of reviews for the Pan Cheshire CDOP.
Key headlines from national data:
3,515 Reviews completed by Child Death Overview Panels in the year ending 31st March 2015 – a year on year decrease from 4,061 in 2011.
A)The percentage of child death reviews identified as having modifiable factors:
24% The percentage of child death reviews (827 reviews) identified as having modifiable factors, an increase from 20% in 2011. (13% in 2014/15 for Pan Cheshire CDOP)
B) Perinatal/Neonatal cases reviewed 2014-2015:
33% The percentage of deaths reviewed which were due to a perinatal/neonatal event; this is broadly consistent with previous years. This is a similar trend within Pan Cheshire (27%) and as such the methodology for the review of neonatal deaths is a priority action for 2015/16.
C)The percentage of deaths reviewed that were for children under one year old in the year ending 31st March 2015
64% The percentage of deaths reviewed that were for children under one year old in the year ending 31 March 2015; this compares with 67% in 2011.(61% under one year old for Pan Cheshire CDOP)
D)Serious Case Reviews
A serious case review was carried out for 2% of all deaths reviewed in the year, which is consistent with previous years. Of the deaths reviewed in 2014-15 that were subject to a serious case review, 79% were deemed to have modifiable factors, compared to 22% of those not subject to a serious case review.(There have been no completed Serious Case Reviews following a child death within Pan Cheshire during 2014/15 and neither has Pan Cheshire CDOP referred a case for consideration of a SCR)
6.Child Death Review Data April 2014 – March 2015 by LSCB
Cheshire East
14 deaths reviewed in total, 10 male deaths and 4 female deaths.
Age range / Male / Female0-27 days / 2 / 3
28 days – 364 days / 1 / 1
1 – 4 years / 3
10 – 14 years / 1
15 – 17 years / 3
Cheshire West and Chester
14 deaths reviewed in total, 8 male deaths, 6 female deaths
Age range / Male / Female0-27 days / 4 / 4
28 days – 364 days / 2 / 2
15 – 17 years / 2
Halton
4 deaths reviewed in total, 4 male deaths, 0 female deaths
Age range / Male0-27 days / 1
28 days – 364 days / 1
1 – 4 years / 2
Warrington
12 deaths reviewed in total, 7 male deaths, 5 female deaths
Age range / Male / Female0-27 days / 2 / 1
28 days – 364 days / 1 / 2
1 – 4 years / 1 / 1
5 – 9 years / 1 / 1
15 – 17 years / 2
What have we achieved?
The following summarises key themes arising from the work of the CDOP in 2013/14 and 2014/15 and an update with regard to progress made.
Safe sleeping
One of the key areas that the CDOP identified from their considerations during 2013/14 was the number of deaths where unsafe sleeping positions or “co-sleeping” had been a modifiable factor. As a result of their considerations, the panel commenced a subgroup to review safe sleep (relating to deaths where co-sleeping or safe sleeping was raised as an issue). In the last 12 months, training sessionshave taken place across the partnership in respect of infant safe sleeping practices. In addition, the CDOP participated in the national Safe Sleep campaign in March 2015.
The Pan Cheshire Integrated Workforce Guidelines for Infant Safe Sleep were ratified in May 2015 and have been disseminated widely through health and children’s services.
Going forward, the CDOP has carried out a parental questionnaire regarding infant safe sleep and will use the results of the survey to review the training and information we give to new parents.
Suicideand self-harm
A Cheshire East Thematic Review of Suicide & Self Harm was carried out in August 2014. The findings were disseminated across the 4 LSCBs. As a result of this review, the CDOP are to develop good practice guidance when working with risk of suicide and self harm.
Child death rapid response in respect of unexpected deaths
The Pan Cheshire SUDIC protocol has been reviewed and updated to ensure consistency across the Cheshire footprint.
The CDOP identified in 2013/14 that a the rapid response process across the Pan Cheshire footprint is not fully compliant with the requirements of Working Together 2013 (and now superseded by Working Together 2015) in that a suitably trained health professional should undertake a visit to the home where a child death occurred, alongside the police. A letter was sent to the six CCGs covering the four LSCB areas advising them that this had been identified. Assurance regarding compliance with statutory guidance is a key priority for 15/16.
CDOP identified that the Ambulance Trust were not following the established processes and protocols for child deaths. The panel wrote to the Ambulance Trust to ensure that they were aware of the protocols so that these could be followed, who in turn made revisions to their safeguarding training.
Identifying deaths in hospital for children aged 16-18 years
When a child reaches the age of 16, in a healthcare setting they are treated as an adult and not placed on a children’s ward or under the care of a paediatrician. As such if a child dies between the ages of 16 and 18 they are treated as an adult. It is possible therefore that some child deaths may not be notified to the CDOP Co-ordinator and therefore a review into the death of that child may not take place. Following a presentation by a Paediatric Consultant from a neighbouring area who had tackled this issue successfully in their own area, the CDOP contacted all the Acute Trusts to request that a similar notification system was put in place. Notifications are now being made promptly.
A local pathway has also been developed to ensure timely notification of child deaths occurring in the community where the child is then taken directly to the mortuary.
Smoking in pregnancy
The CDOP identified in 2013/14 that there were a number of cases where the mother had smoked during pregnancy, smoking in pregnancy can lead to a range of health issues for newborns as well as premature births and faltering growth in babies. The panel wrote to acute trusts and Directors of Public Health requesting that reducing smoking in pregnancy remain a key priority through smoking cessation services and through specially trained midwives who work with mothers to reduce the numbers smoking in pregnancy. In the last 12 months, smoking specialist nurses have attended the Safe Sleep Training to provide resources and information on smoking cessation.
Dissemination of learning
In order to promote closer working with the Merseyside CDOP, the Pan Cheshire CDOP nurses and administrator now attend the Merseyside CDOP for the exchange of information and learning within the Region.
CDOP Priority Action Plan 2015-16
Priority / Action / Timescales / OutcomeReview the effectiveness of CDOP business processes /
- Agee representative membership across the 4 LSCBs
- Agree quoracy
- Establish feedback mechanisms
- Review process for parental engagement
- Improve timeliness of reviews
- CDOP development day for panel members
Impact evaluation of CDOP /
- Action log to be introduced
- Review of 14/15 deaths with modifiable factors
Increase the profile of CDOP /
- Develop Pan Cheshire web pages
- Establish seasonal newsletter
- Seminar to be developed for partner agencies across Pan Cheshire
Neonatal deaths /
- Establish a thematic approach to neonatal death reviews
- Monitor prevalence of high BMI and smoking in pregnancy and seek assurance regarding awareness raising and support within antenatal services
Safe Sleep /
- Analysis of parent questionnaires to establish knowledge of safe sleep practices
Suicide and self harm /
- Develop Pan Cheshire Good Practice Guidance
Publication of SUDIC protocol /
- Revised protocol to be published
Review of compliance with Working Together 2015 and consider future options for delivery of a rapid response /
- Assurance to be provided by commissioners with regard to compliance with statutory guidance
Appendices: