Stockport, Tameside and Trafford Child Death Overview Panel

STOCKPORT, TAMESIDE AND TRAFFORD CHILD DEATH OVERVIEW PANEL

ANNUAL REPORT - 2014/15

Report Authors

Mick Lay – Independent CDOP Chair

Jacqueline Dorman – Public Health (Tameside MBC)

1 CONTENTS

SECTION ONE – EXECUTIVE SUMMARY

1.1 Introduction.

1.2 The Panel and its functions.

1.3 Childhood deaths and key issues in 2014/15

1.4 Number of Childhood deaths

1.5 Ages of children.

1.6 Ethnicity.

1.7 Sudden Unexplained Death in Infancy (SUDI)

1.8 Unexplained deaths in young people

1.9 Modifiable Factors

SECTION 2 – RECOMMENDATIONS

2.1 Recommendation updates from 2012/13

2.2 Recommendations for 2013/14

SECTION 3 – DATA ANALYSIS

3.1 Number of child deaths (notifications 2014/15)

3.2 Trends in child deaths (notifications)

3.3 Number of child deaths 2014/15

3.4 Expected and unexpected deaths

3.5 Ages of children 2014/15

3.6 Ages of children 2013/14

3.7 Birth Weight

3.8 Categories of Death

2 3.9 Percentage of deaths by category.

3.10 Categories of death compared to age range.

3.11 Number of Deaths in Children U’ 1 by Category of Death

3.12 Percentages of 3 main causes of death in children U’1

3.13 Ethnicity of children

3.14 Ethnicity and age.

3.15 Deaths in children by ethnicity based on population breakdown

3.16 Deaths in children by ethnicity

3.17 Ethnicity by Category of Death (Stockport, Tameside and Trafford combined)

3.18 Ethnicity by Category of Death (Percentages)

3.19 Number of child deaths based on Deprivation Quintile

3.20 Number of deaths in age ranges set against deprivation quintiles

3.21 Sudden unexplained deaths in infancy (SUDI)

3.24 Additional Information on Injuries

Appendix National Form detailing categories of death

SECTION 1 - EXECUTIVE SUMMARY

1.1 Introduction. 3 Child Death Overview Panels (CDOPs) are a multi-disciplinary sub-group of Local Safeguarding Children Boards that work across Local Authority boundaries based on population numbers. The CDOP reviews the deaths of all children aged from birth to under the age of 18 years old (excluding still births and planned terminations carried out under the law) who normally reside within the geographical boundaries of that CDOP.

There are 4 CDOPs across Greater Manchester, 3 of which are ‘tri-partite’ such as Stockport, Tameside and Trafford (STT) with one CDOP covering the area of Manchester City Council. This report provides information on the child deaths which have occurred in 2014/15 known as ‘notifications’ and cases concluded by the CDOP referred to as ‘closed’.

It is important to recognise that not all notifications received in 2014/15 (beginning of April to the end of March) are dealt with in that 12 month period. Notifications received later in the year require information to be gathered which means they will be considered in the next 12 month period. Equally some cases may result in coronial inquests, police investigations and in some cases Serious Case Reviews. The nature of these investigations mean there will often be significant periods between the notification to CDOP and the case being discussed and closed by CDOP.

In 2014/15 there were 51 notifications to CDOP but 54 cases were closed by the panel.

The first two sections of this report outline the functions of the Panel and summarise its key findings. In turn these key findings support the recommendations which are made to each of the three Local Safeguarding Boards (LSCBs) named above. These first 2 sections do not contain any identifiable data and are therefore appropriate for wider circulation. A more detailed analysis of the data in Section 3 for consideration by professionals involved in child safeguarding may contain identifiable information and therefore has a restricted circulation.

1.2 The Panel and its functions.

Government advice is that Child Death Overview Panels should cover populations of at least 500,000 and it was for this reason that the three authorities of Tameside, Stockport and Trafford came together from 1st April 2009. The CDOP carries out a multi-disciplinary review of child deaths (0-17 years inclusive) with the aim of understanding how and why children in Stockport, Trafford and Tameside die. Panel members consider whether there are any factors which could have been modified to prevent or reduce the chances of a similar death in future.

1.3 Childhood deaths and key issues in 2014/15.

One of the significant challenges for the Panel is to draw conclusions from a (thankfully) relatively small number of cases each year. CDOPs have been gathering data since 2008 and the collection of data from various agencies has improved year on year. The main issues for the CDOP are to consider the number of deaths and the reasons for those deaths with a view to detecting trends and/or specific areas which would appear worthy of further consideration. In order to draw some conclusions this report includes some comparative year on year historic data. This means that larger

4 numbers and longer terms trends can be analysed. The data collection process and analysis around CDOP has continued to develop both locally and across Greater Manchester. This has resulted in the production of a Greater Manchester CDOP annual report which is able to analyse trends using larger numbers. The GM report will be published later in September 2015 but in general terms the consistent issues will continue to be deaths in children under 1 year. These deaths have consistent themes around prematurity, parental smoking (particularly by mother), low birthweight and life limiting conditions when the child is at its most vulnerable.

1.4 Numbers of Childhood deaths.

There were a total of 51 childhood deaths notified to the CDOP in 2013/14. Since 2007/8 there have been a total of 446 child deaths across the 3 areas and as might be expected there are year on year variations. When the numbers of deaths 2007-2015 across the CDOP are compared to the total under 19 population across the 3 areas of the CDOP, Stockport accounts for 35% of the child deaths and has 38% of the under 19 population. Tameside accounts for 33.6% of the child deaths with 30% of the under 19 population. Trafford accounts for 31.4% of the child deaths with 32% of the under 19 population.

1.5 Ages of children.

In 2013/14 61% of deaths in this CDOP were children under 1year old and this figure has been consistent over recent years. However, in 2014/15 the figure across the CDOP area dropped to 55%. The figure across GM remained at 61%. Of the 55% there continues to be a higher incidence of children under 27 days which ranges year on year between 28%-55%.

In 2014/15 the rate for 0-27 days was 36.8% in this CDOP. Consistent features in these deaths are prematurity where the infant is too under developed or because of severe life limiting conditions when the child is at its most vulnerable.

1.6 Ethnicity.

In the early years of CDOP data around ethnicity was not always collected in a robust manner which limits year on year comparisons. Equally when broken down into local authority areas, in individual years the relatively small numbers must carry a warning on their statistical significance. From the available data since 2009 it appears that both Tameside and Trafford have slightly higher percentages of BME child deaths than might be expected when set against the BME child population per 10,000.

1.7 Sudden Unexplained Death in Infancy (SUDI)

In 2014/15 the CDOP identified 4 SUDI cases. Across GM there were 19 cases and only Bolton did not have at least 1 incident. The common features in these cases were that parents smoked and/or had been co-sleeping with their child in bed or on a settee (see modifiable factors at 1.9 below). Research shows that the North West and Wales have the highest rate of sudden unexplained deaths in England and Wales.

5 1.8 Unexplained deaths in young people

The intention of the individual in these deaths involving, in the main, adolescents, is often unclear and accordingly Coroners in GM rarely if ever record a finding of suicide. There were 9 such incidents in GM where children died and illness was not the cause nor was there any evidence of third party involvement. In addition to the work by all CDOPs research is being carried over the next 2 years at the University of Manchester into deaths of this nature.

1.9 Preventable Deaths/Modifiable Factors.

National guidance defines potentially preventable child deaths as those in which modifiable factors may have contributed to the death. These factors are defined as those which, by means of nationally or locally achievable interventions, could be modified to reduce the risk of future child deaths.

Cases can only be closed when all other processes such as Inquests, criminal investigations and Serious Case Reviews have concluded. In 2014/15 a total of 54 cases were closed by the panel. Of those, 17 (31%) were identified as having modifiable factors. In 2012/13 corresponding figures were 18%; and in 2013/14 27%. In 2013/14 the average across GM was 27% and nationally 22%.

Where modifiable factors exist consistent features are smoking by mothers in pregnancy, prematurity and associated low birth weight.

SECTION 2 – RECOMMENDATIONS

2.1 Update on recommendations from 2013/14

1/ There is evidence of a disproportionate number of child deaths in Quintile 1(most deprived). Each Authority should assess the work currently in place to target vulnerable groups and an action plan should be developed to identify how the number of deaths can be reduced.

Stockport - A core group of specialists have met and reviewed the current procedures. A draft document has been formulated and will be taken to SSCB on 18th May for approval. 6 Tameside - giving priority to vulnerable groups is built into service specifications, the Health and Wellbeing Strategy, Early Years Strategy, Early Help Strategy and work on Complex Families. All health and social care services work within a model of universal, universal plus and universal partnership plus provision that enables a proportionate response to need that recognises a wide range of vulnerabilities. Going forward, health and social care services are in scope for the local ‘Care Together’ health and social care integration programme, and the need to give appropriate priority to vulnerable groups is being built into the design, specification and tendering of new services.

Trafford - the integrated CYPS service model ensures that health visiting and FNP are embedded in our early help offer. This ensures that vulnerable families are quickly identified and offered the right support by the right service. There is a safeguarding board which works collaboratively with local services, focusing on supporting the whole system to safeguard our most vulnerable.

The impact of health and socioeconomic inequalities on outcomes is addressed in Trafford Children and Young People’s Plan 2014-2017.

2/ It is a consistent feature, both locally and nationally, that children under 1 year old account for two thirds of child deaths. These deaths have common features around low birth weight, prematurity and maternal smoking and associated issues of hypertension, diabetes and obesity. Given that year on year the percentage of deaths remains this high, Public Health should review current work and devise an updated action plan to address the areas identified.

Stockport –a small team of professionals have produced a 10 page document and action plan of ongoing work in Stockport. Below is a summary of that document which is available in full.

Work is ongoing within the national programme ‘saving babies lives’ and a care bundle is being defined which includes smoking cessation and monitoring of foetal movement and growth. Proactive work is carried out to address diet of pregnant mothers and blood pressure is checked at all appointments. Stockport has a specialist midwife who leads on maternal smoking cessation. CO monitoring takes place with those identified as smokers. Safe sleeping advice is documented and followed up by midwife and health visitors. It is also covered at parent education classes. Diabetes – a specialist midwife is in place and maternity staffs receive mandatory training. First time parents under 20 are targeted as a potentially vulnerable group and there is in place a specialist teenage pregnancy midwife. Integrated children’s services have been established to bring together a range of services such as health visiting, children’s centres and social care.

Tameside -The local Healthy Weight Strategy and Tobacco Control Strategy give priority to work with pregnant women. Tameside Hospital maternity service is currently involved in two pilots of novel approaches to stop smoking in pregnancy, the outcomes of which should be available in 2015.There is a Maternity Healthy Weight Pathway in place which has been reviewed and revised during 2014. The infant mortality rate for Tameside is lower than expected considering its level of social deprivation.

Trafford- there is a multi-agency Maternal and Child Health Forum which meets quarterly. All issues relating to pregnancy, birth and childhood are addressed through this forum. The forum has a solution focused approach to issues which may be impacting on the health and wellbeing of mothers and children across Trafford.

7 3/ Injury is a significant factor in childhood deaths, particularly in the older age ranges. Evidence indicates that Tameside in particular has a high rate of admissions, (5th highest rate in the GM table) and higher than the GM average. It is recommended that Public Health carry out work to analyse the injury admissions with a view to identifying any correlation with the CDOP data.

Stockport – whilst figures compare well with those across the region they are still above the national average. There is a child injury prevention officer in post since Oct 2014

Tameside -A project in response to a previous high rate reviewed local data and accident prevention activity, identified accidents at home in under 5s as a key issue, and secured funding for a partnership programme to provide home safety equipment. A further project tin response to new data is currently in progress focussing on data quality and clinical pathways, and will report during 2015.

4/ CDOPs have been in existence since 2007 and child deaths have remained relatively constant over this time period. It is recommended that a 5 years ‘snapshot’ is under taken across the 3 Authorities and GM to evaluate CDOP data in more detail. This would allow standardisation of the data sets, complete correlation to understand if there is a relationship between child deaths and areas such as smoking at time of delivery (SATOD), deprivation, and ethnicity. It would also allow robust benchmarking to take place across GM to highlight Local Authorities that need more support in reducing child deaths in their area.

GM Representatives from PH across GM met in March to agree ToR for the group. A number of key themes were identified in line with the recommendation above. Andrea Fallon has picked up key actions to progress.

2.2 RECOMMENDATIONS BASED ON THE 2014/15 REPORT

Whilst the number of child deaths varies each year the overall numbers show little change since 2008. This report and previous CDOP annual reports provide evidence that there are key factors which could have a significant impact in reducing the number of child deaths.

In previous years recommendations have focussed on these key factors but with numbers in each area being thankfully small it has not proved possible to measure the effectiveness of any one factor in any one locality. This will prove even more difficult for each LSCB as the provision of services continues to move toward larger centres of excellence and reduction of smaller local services.

In the last 2 years great strides have been made by CDOPs working more closely with Public Health at local, GM and regional level. Public Health staff now play a vital role in analysing the data collected and collated by CDOPs and with that collaboration annual reports are now produced for each CDOP as well as Greater Manchester and, from last year, a regional report.

8 Many of the issues identified in this report are not specific to one local authority and whilst each LSCB should retain its autonomy and be held accountable it must fall to Public Health, working with CDOPs at a local, regional and national level to address the key issues identified in this and previous reports.

Updates provided from the recommendations made in 2013/14 provide evidence that Public Health is working to address these key factors but at this point several are either pilots or under review and no figures as to uptake or effectiveness have been produced. It is equally the case that Directors of Public Health across GM are aware of the 2013/14 recommendations contained in the GM CDOP Annual Report and have met on several occasions to discuss the best way forward.

It is the recommendation from this report that each LSCB ensure that Public Health take the lead in providing evidence of the work being carried out both locally and across GM that will have an impact on reducing the number of child deaths.

Based on the evidence in this report the areas which require specific focus are –

 Actions to prevent premature births which have a disproportionate effect on the child mortality rate.

 Actions to identify and then focus on groups where risk appears to be highest based on ethnicity and deprivation.

This will involve PH providing each LSCB with evidence of its action plans already in place to address the areas above and how these actions will be measured for outcomes.

SECTION 3 – CASE ANALYSIS

When a child dies any or all of the agencies involved with the child should inform the CDOP administrator for that geographic area. This is referred to as a ‘notification’. The administrator then begins to gather information from all sources who may know the child and/or family in order to build a picture of the circumstances leading up to the death of the child. From April to the end of March each year the CDOP collects data on the number of ‘notifications’ that year.

Once all the available and relevant information is collected and all other investigations involving the Coroner, Police or Children’s Services have been concluded, the CDOP review each case. Having assessed all the available information the panel, made up of professionals from a number of agencies, discuss the relevant points and reach a conclusion regarding the category of death and any modifiable factors or issues specific to that case. At this point the ‘notification’ is considered by the CDOP to be ‘closed’. Dependant on the date of death or ongoing investigations the ‘notification’ might not be ‘closed’ in the same year.

9 In 2014/15 the panel concluded a total of 54 cases, 27 (50%) of which had been notified during 2014/15 with a further 19 (35%) being notifications from 2013/14. The remaining 8 (15%) were older and had been delayed being dealt with CDOP due to ongoing investigations by either the police, coroner or local authority reviews whether single agency or Serious Case Reviews (SCR)

3.1 Number of child deaths (notifications 2014/15)

Total LA Deaths Stockport 15 Tameside 18 Trafford 18 STT total 51 Greater Manchester 241

3.2 Trends in child deaths (notifications)

Total Deaths LA 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 Stockport 24 17 23 20 17 19 21 15 Tameside 16 21 17 26 25 16 11 18 Trafford 13 23 22 18 10 15 21 18 STT total 53 61 62 64 52 50 53 51

From the charts above and graph below it can be seen that the overall number of deaths has dropped slightly since 208/9-2010/11 but other than those 2 years have remained constant. Stockport has recorded its lowest number of deaths this year.

Trends in child deaths illustrate that across Stockport, Tameside and Trafford, child deaths have fluctuated somewhat over the last 8 years. Since 2007/08 there have been a total of 446 notified deaths across the three boroughs of Stockport, Tameside and Trafford, with Stockport making up 35%, followed by Trafford 34% and Tameside 31%. 10 Looking in depth at the data for Trafford, more than half of their entire child deaths were in children aged under 4years (64.5%) with the majority of these deaths being in 0-27 days (31.6%) and 1 to 4 years (24.5%). Of the 25 deaths that occurred in Trafford the main causes of death were perinatal (40%), acute medical (12%) and malignancy (12%)

Preterm birth occurs for a variety of reasons. Most preterm births happen spontaneously, but some are due to early induction of labour or caesarean birth, whether for medical or non-medical reasons.

Common causes of preterm birth include multiple pregnancies, infections and chronic conditions, such as diabetes and high blood pressure; however, often no cause is identified. There is also a genetic influence. Better understanding of the causes and mechanisms will advance the development of solutions to prevent preterm birth.

From a child death perspective although overall child deaths have fluctuated over the last eight or so years there as not been any consistent decrease; It is therefore important to gain a perspective into the wider determinates of all child deaths and in particular into those deaths that occur in infants.

From this point on all references will be concerning cases which have been to panel, fully discussed and classed as ‘closed’.

3.3 Number of child deaths 2014/15 (closed cases)

Total LA Deaths Stockport 15 Tameside 14 Trafford 25 STT total 54 Greater Manchester 262

Between the three local authorities of Stockport, Tameside and Trafford, Trafford had the most child deaths (closed cases) for 2014/15. For Trafford this is a 40% increase since 2013/14. The apparent increase may well be due to cases becoming available to the panel for the reasons given above. In 2013/14 the panel only closed 15 cases from Trafford but closed 29 from Stockport and only 15 this year which would tend to support the assertion.

Whilst there will be some variations year on year in terms of actual numbers reference to previous years show a consistent pattern particularly when looking at deaths in children under 1 year old, ethnicity and deprivation.

3.4 Expected and unexpected deaths (closed cases) 11 Expected Unexpected Not Known No Data Total LA No % No % No % No % No Stockport 11 73.3% 4 26.7% 0 0.0% 0 0.0% 15 Tameside 9 64.3% 5 35.7% 0 0.0% 0 0.0% 14 Trafford 13 52.0% 12 48.0% 0 0.0% 0 0.0% 25 Stockport, Tameside, Trafford33 61.1% 21 38.9% 0 0.0% 0 0.0% 54 Greater Manchester 160 61.1% 94 35.9% 1 0.4% 7 2.7% 262

An unexpected death is defined as the death of an infant or child which was not anticipated as a significant possibility for example, 24 hours before the death; or where there was an unexpected collapse or incident leading to or precipitating the events which lead to the death.

For GM overall there were more expected deaths than unexpected and this is a similar pattern for Stockport and Tameside. However unexpected and expected deaths in Trafford were similar.

18 (55%) of the expected deaths were children under 28 days. A further 5 (15%) were under 1 year old. Consistent factors in these deaths are prematurity and life limiting conditions.

Of the unexpected deaths the range of categories was far wider including SUDI, non-intentional injury as well as life limiting conditions where death was not anticipated in the previous 24 hours as per the guidance above.

10 (30%) of the 33 expected deaths were classified as having modifiable factors which in the main related to smoking where the child was born prematurely.

3.5 Ages of children 2014/15 (closed cases)

0-27 days 28-364 days 1-4 years 5-9 years 10-14 years 15-17 years Total % of % of % of % of % of % of Local Authority Number overall Number overall Number overall Number overall Number overall Number overall Number deaths deaths deaths deaths deaths deaths Stockport 7 49.0% 4 24.8% 0.0% 1 6.4% 1 7.8% 2 12.0% 15 Tameside 5 33.1% 4 29.3% 0.0% 2 14.4% 1 7.8% 2 15.3% 14 Trafford 8 31.6% 2 8.4% 6 24.5% 2 8.5% 3 11.7% 4 15.4% 25 Stockport, Tameside, Trafford20 36.8% 10 18.5% 6 11.2% 5 9.5% 5 9.6% 8 14.4% 54 Greater Manchester 109 40.3% 60 21.6% 25 10.8% 17 7.3% 24 8.7% 27 11.3% 262

When data is broken down into age bands, it can be seen the area with the highest number of deaths are those under the age of one year, with deaths in the age bands making up more than half of all child deaths. However, in 2014/15 Stockport were shown to have a 10% higher death toll in this age group compared to the CDOP area average but this is similar to the GM average. There is also a clear one year jump in Trafford in the 1-4 age group. Analysis of these cases show no apparent pattern with a spread of causes, gender and ethnicity. This may well be a one off but will be compared in future reports to ensure any possible trends are identified.

3.6 Ages of children 2013/14 (closed cases)

12 0-27 days 28-364 days 1-4 years 5-9 years 10-14 years 15-17 years Total % of % of overa overa Local Authority Numb Num Number Number % of Number % of Number ll ll Number er ber % of overall overall overall death % of overall death deaths deaths deaths s deaths s Stockport 16 55% 7 24% 1 3% 2 7% 0% 3 10% 29 Tameside 5 28% 4 22% 3 17% 1 6% 2 11% 2 17% 17 Trafford 5 33% 3 20% 2 13% 2 13% 2 13% 1 7% 15 Greater Manchester 90 42% 48 22% 26 12% 19 9% 20 9% 13 6% 215

It can be seen that when comparing the above 2 charts, whilst the numbers vary, the percentages show that Stockport have almost 74% of deaths in the U’1 age range and 79% the previous year.

Tameside have just over 62% in 2014/15 but 50% the previous year.

Trafford have just over 53% in 2013/14 which is the same as 2013/14.

The GM average remains almost the same at 62% and 64%.

3.7 Birth Weight

1500g- Not Grand LA <1500g 2499g 2500g+ Stated Total Stockport 7 2 4 2 15 Tameside 4 1 9 0 14 Trafford 7 1 13 4 25 Stockport, Tameside, Trafford18 4 26 6 54 Greater Manchester 84 27 100 51 262

The data in the birth weight tables and chart show that child deaths were significantly higher in babies born of a low birth weight. The higher numbers in Tameside and Trafford of 2500g+ were in the main due to life limiting conditions.

Not LA <1500g <2500g 2500g+ Stated Stockport 46.7% 60.0% 26.7% 13.3% Tameside 28.6% 35.7% 64.3% 0.0% Trafford 28.0% 32.0% 52.0% 16.0% Stockport, Tameside,33.30% 40.70% Trafford 48.10% 11.10% Greater Manchester32.1% 42.4% 38.2% 19.5%

13 70% <1500g <2500g 60%

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0% Stockport Tameside Trafford Stockport, Greater Tameside, Manchester Trafford

Low birth weight is a more common outcome than Infant mortality 1, and interventions to reduce infant mortality and low birth weight are central to giving every child the best start in life and reducing health inequalities across the life course. Low birth weight has many causes including smoking in pregnancy. It can also be caused by maternal stress during pregnancy. Low birth weight is more prevalent amongst the lower socio-economic classes and a key indicator of health inequalities. Nationally mothers resident in the most deprived areas had a 2-fold increase in stillbirth and neonatal mortality rates. Reducing the incidence of low birth weight thus remains of high priority to public health.

3.8 Categories of Death. The 10 national indicators.

When CDOP members consider a case one of the specifics they must address is the ‘category of death’. In order to provide some consistency from panels across the country the Department for Education created 10 classifications which are shown below together with the numbers and percentages for this CDOP and Greater Manchester as a whole in 2014/15.

1 Risk-factors-for-low-birthweight-based-on-birth-registration-and-census-information--england-and-wales-- 1981-2000.

14 Acute Trauma and Chromosomal/ Chronic Suicide or Perinatal/ medical/surg Sudden other External Genetic/ medical Deliberate Infection Malignancy Not known Total Self-Harm Neonatal ical Unexpected LA Sources congenital Condition condition

No % No % No % No % No % No % No % No % No % No % No % Stockport 1 6.7% 0 0.0% 7 46.7% 0 0.0% 2 13.3% 1 6.7% 0 0.0% 0 0.0% 2 13.3% 2 13.3% 0 0 15 Tameside 1 7.1% 1 7.1% 4 28.6% 0 0.0% 3 21.4% 1 7.1% 0 0.0% 0 0.0% 1 7.1% 3 21.4% 0 0 14 Trafford 0 0.0% 1 4.0% 10 40.0% 3 12.0% 1 4.0% 2 8.0% 2 8.0% 2 8.0% 3 12.0% 1 4.0% 0 0 25 STT 2 3.7% 2 3.7% 21 38.9% 3 5.6% 6 11.1% 4 7.4% 2 3.7% 2 3.7% 6 11.1% 6 11.1% 0 0 54 Greater Manchester 14 5.3% 9 3.4% 97 37.0% 9 3.4% 68 26.0% 10 3.8% 5 1.9% 12 4.6% 18 6.9% 19 7.3% 1 0.4% 262

When looking at cause of death the above table shows that the highest proportion of deaths were perinatal/neonatal deaths. The next largest proportion of deaths were from the chromosomal/congenital, malignancy and sudden unexpected category

Congenital anomalies are the second most common cause of infant deaths in England and Wales; although the vast majority of infants born with a congenital anomaly will survive. There are many different congenital anomalies and the cause of most is not known. In any single year infant deaths due to congenital anomalies are associated with over 150 different causes. Congenital anomalies contribute about one third of the extra infant deaths experienced by the routine and manual socioeconomic groups compared with the population as a whole.2

Some areas in GM have noted a number of deaths where the parents are related other than through marriage – consanguinity. In this CDOP there were 2 deaths dealt with in 2014/15 (1 each in Stockport and Trafford) where parents were 1st cousins and the category of death was recorded as chromosomal or genetic anomaly.

3.9 Percentage of deaths by category.

2 Kurinczuk JJ, Hollowell J, Brocklehurst P, Gray R. Inequalities in Infant Mortality Project Briefing Paper 1.Infant mortality: overview and context. Oxford: National Perinatal Epidemiology Unit, University of Oxford. 2009.

15 3.10 Categories of death compared to age range.

The table and chart above show that the highest numbers of deaths occur in children under 1 year. In the majority of cases these deaths are linked to prematurity, low birth weight or life limiting conditions. As children get older the range of categories increases

3.11 Number of Deaths in Children U’ 1 by Category of Death

16 Chromosomal, Sudden Perinatal/neona genetic and unexpected, tal event congenital unexplained anomalies death Stockport 7 2 2 Tameside 4 3 2 Trafford 9 0 1 Stockport, Tameside, Trafford 20 5 5

3.12 Percentages of 3 main causes of death in children U’1

17 Chromosomal, Sudden Perinatal/neona genetic and unexpected, tal event congenital unexplained anomalies death

Stockport 63.6% 18.2% 18.2% Tameside 44.4% 33.3% 22.2% Trafford 90.0% 0.0% 10.0% Stockport, Tameside, Trafford66.7% 16.7% 16.7%

The 2 charts and 2 graphs at 3.10 and 3.11 above show the highest categories of death in children U’1.

There is clear evidence that perinatal/neonatal events are the biggest factor. In these cases it is known by examining each case that the most common features in these deaths are mother smoking in pregnancy, high BMI and prematurity with the associated factors of low birth weight and under developed organs.

The graph at 3.11 showing the main 3 areas taken as percentages indicates that across the CDOP area some 67% of deaths U’1 are attributable to perinatal/neonatal events.

18 3.13 Ethnicity

Asian White Black Mixed race Not Known Other/not specified Total Local Authority % of % of % of % of % of % of Number Number Number Number Number Number total total total total total total Stockport 3 21.8% 10 65.4% 0 0.0% 2 12.8% 0 0.0% 0 0.0% 15 Tameside 1 7.9% 11 79.1% 1 6.0% 1 7.0% 0 0.0% 0 0.0% 14 Trafford 3 12.8% 16 63.0% 2 7.3% 3 13.2% 0 0.0% 1 3.7% 25 STT 7 14.0% 37 68.0% 3 4.9% 6 11.4% 0 0.0% 1 1.7% 54 Greater Manchester 59 27.6% 156 56.3% 22 7.1% 20 7.3% 1 0.2% 4 1.4% 262

3.14 Ethnicity and age.

3.12 and 3.13 above show that as well as the numbers of child deaths being disproportionate to the population makeup there is also a disproportionate representation when ethnicity is compared to age of death. 7 (70%) of Black and Asian deaths occur under 1 year and all deaths in this group occur before the age of 9 years old.

3.15 Chart showing deaths by ethnicity based on rate per 10,000

White BME Local Authority Rate/10,000 Rate/10,000 Number Number population population Stockport 10 1.9 5 6.3 Tameside 11 2.6 3 4.2 Trafford 16 3.8 9 7.5 STT 37 2.7 17 6.3 Greater Manchester 156 3.4 105 6.8

Although more deaths occurred in the white indigenous population across Stockport, Tameside and Trafford; when interrogating the data further on child deaths in relation to ethnicity, crude rates per/10,000, based on population proportions show that more deaths occurred in the BME population per 10,000 in Stockport, Tameside and Trafford than in the white British population. (6.8/10,000 compared to 2.7/10,000)

19 3.16 Graph showing deaths by ethnicity per 10,000

3.17 Ethnicity by Category of Death (Stockport, Tameside and Trafford combined)

20 3.16 and 3.17 above and 3.18 below show that whilst perinatal and neonatal deaths dominate the category of deaths in the white population there is also a spread of deaths in other categories. This spread is not present in the BME deaths of children.

3.18 Ethnicity by Category of Death (Stockport, Tameside and Trafford Combined) Percentages

It has been clear for over 100 years that infant mortality rates in England follow a social gradient; 3 rates are lowest in the most advantaged families, highest in the most disadvantaged and lie in between the two for those intermediate families.

Large inequalities in infant mortality rates exist between White and ethnic minority groups in England and Wales. 4

 Caribbean and Pakistani babies are more than twice as likely to die before the age of one as White British or Bangladeshi babies, in part due to a higher prevalence of preterm birth and congenital anomalies, respectively, in these particular groups.  There is considerable heterogeneity between different ethnic groups in both the causes and the risk factors for infant mortality.  Explanations for variations in infant mortality between ethnic groups are complex, involving the interplay of deprivation, physiological, behavioural and cultural factors.  More research is needed in order to identify the pathways that lead to higher risks of infant death among Black and other ethnic minority groups.

3 https://www.npeu.ox.ac.uk/downloads/files/infant-mortality/Infant-Mortality-Briefing-Paper-2.pdf 4 https://www.npeu.ox.ac.uk/downloads/files/infant-mortality/Infant-Mortality-Briefing-Paper-3.pdf 21 3.19 Number of child deaths based on Deprivation Quintile

Q5 (Least Q1 (most Not Total LA deprived) Q4 Q3 Q2 deprived) Known deaths Stockport 1 5 3 0 6 0 15 Tameside 0 0 2 5 7 0 14 Trafford 8 3 2 7 5 0 25 STT 9 8 7 12 18 0 54 Greater Manchester 19 19 27 44 149 4 262

When looking at deprivation quintiles, the data in the table above shows that for Tameside, more children died in the most deprived quintile than in any other quintile. However this pattern is not matched for Trafford or Stockport.

The pattern of highest number of child deaths coming from families in the most deprived quintiles is repeated in age at death, category of death and also ethnicity.

As indicated above a more comprehensive piece of work will be undertaken in 2016 looking at possible trends in key areas, such as deprivation, to determine any possible actions.

3.20 Number of deaths in age ranges set against Deprivation Quintiles

22 It can be seen that the highest number of deaths in children (U’1) have a disproprtionate representation in quintiles 1 and 2. (Most deprived)

3.21 Sudden unexplained deaths in infancy (SUDI)

Area Age Sex/Ethnicity Issues

Stockport 28-354 days Female/Mixed Co-sleeping. Parental drug use and smoking. Quintile 1 (most deprived)

Stockport 28-354 days Male/White Parents smoked. Mother had suffered post natal depression. Quintile 1

Tameside 28-364 days Male/White Co-sleeping. Mother had suffered post natal depression. Substance mis-use. Domestic abuse. Quintile 1

Tameside 28-364 days Male/Mixed Parents smoked. Mother assessed for depression. Overcrowding.Quintile 1

Trafford 28-364 days Female/Mixed Quintile 2 23 In 2014/15 the CDOP identified 5 SUDI cases. Across GM there were 19 cases and only Bolton did not have at least 1 incident. The common features in these cases are parental smoking, mis-use of alcohol and/or drugs, history of depression, co-sleeping with their child in bed or on a settee and family reside in most deprived quintiles. Research shows that the North West and Wales have the highest rate of sudden unexplained deaths in England and Wales.

The intention of children who die other than from illness or involvement of a third party is often unclear. On that basis Coroners in GM rarely if ever record a finding of suicide. There were 9 such incidents closed by CDOPs in GM in 2014/15. Two of these cases occurred in in Tameside and Trafford in 2012 and 2014 respectively. Both were white males aged 15-17. The Trafford case was by hanging and the Tameside case was asphixiation.

Research is being carried over the next 2 years by staff at the University of Manchester into deaths of this nature and involves information gathered by CDOP who will play a role in assisting the research.

Guidance defines preventable child deaths as those in which modifiable factors may have contributed to the death. These are factors defined as those, where, if actions could be taken through national or local interventions, the risk of future child deaths could be reduced.

Cases can only be closed when all other processes such as Inquests, criminal investigations and Serious Case Reviews have concluded. In 2014/15 a total of 54 cases were closed by the panel.

Of those 17 (31%) were identified as having modifiable factors. Across GM the figure was 24%

In 2013/14 the CDOP figure was 27%. The average across GM was 27% and nationally 22%.

In 2012/13 the CDOP figure was 18%.

24 Modifiable Modifiable factors not Not Stated Total LA factors identified identified No % No % No % No Stockport 5 33.3% 10 66.7% 0 0.0% 15 Tameside 7 50.0% 7 50.0% 0 0.0% 14 Trafford 5 20.0% 20 80.0% 0 0.0% 25 STT 17 31.5% 37 68.5% 0 0.0% 54 Greater Manchester 63 24.0% 198 75.6% 1 0.4% 262

The table above illustrates that the majority of child deaths in Tameside, Stockport and Trafford had no modifiable factors attached to them (68.5%). However for Tameside deaths from both modifiable and non-modifiable were equal.

STOCKPORT

AGE SEX/ETHNICITY ISSUES/MODIFIABLE FACTORS

Child1 – 0-27 days Male/White Prem(21weeks). Mother smoked during pregnancy. BMI 32

Child 2 – 0-27 days Male/BME SUDI. Co-sleeping. Smoking by parents and mother during pregnancy.

Child 3 – 0-27 days Female/White Prem (22 weeks) smoking by mother.

Child 4 – 28-365 days Male/White SUDI. Smoking by mother during pregnancy.

Child 5 – 0-27 days Male/White Prem (23 weeks) mother smoked during pregnancy

25 TAMESIDE

AGE SEX/ETHNICITY ISSUES/MODIFIABLE FACTORS Child1 – 5-9 years Female/Asian Road Traffic Collision. Seat belt not worn.

Child 2 – 28-365 days Male/White SUDI. Co-sleeping. Alcohol and substance misuse.

Child 3 – 14-17years Male/White Hanging. Prior access to healthcare.

Child 4 – 28-365 days Female/White Heart disease. Mother smoked tobacco and cannabis during pregnancy.

Child 5 – 0-27 days Female/White Prem (31 weeks) mother smoked during pregnancy. BMI 37. Child 6 – 28-365 days Male/White SUDI. Smoking by mother. Child 7 –0-27 days Male/White Prem (23 weeks). Mother smoked during pregnancy.

TRAFFORD

AGE SEX/ETHNICITY ISSUES/MODIFIABLE FACTORS

Child1 – 1-4 years Male/White Access to healthcare in post- operative phase. Child 2 – 1-4 years Male/White Respiratory failure whilst on waiting list. Lack of donor Child 3 – 0-27 days Male/White Prem. (22 weeks) Mother smoked during pregnancy. BMI 38. Child 4 – 0-27 days Male/BME Prem (21 weeks) Twin. Mother smoked during pregnancy. BMI 38. Child 5 – 0-27 days Female/BME Prem (21 weeks) Twin. Mother smoked during pregnancy. BMI 38.

Where modifiable factors exist consistent features are smoking by mothers in pregnancy, prematurity and associated low birth weight.

There are 3 cases where access to healthcare was felt by the panel to have been a factor which, if improved, may have prevented the death. Locally issues have been dealt with by action plans seen and agreed by the panel. Nationally it was felt that an ‘opt out’ rather than ‘opt in’ policy of organ donation would be a positive step. This has been raised with other CDOPs in the region to take forward at a national level but without any development at this time.

26 3.24 Additional Information on Injuries

Injuries place a large burden on individuals, families, communities and public services, including health and the criminal justice system.

In 2014/15 there were 13 children aged 1to 17 who died unexpectedly, 62% of these deaths were due to injury or accident. (In 2013/14 10 children aged 1- 17 died unexpectedly and 30% of these deaths were due to injury)

Across Tameside there are high levels of childhood injury resulting in Tameside having a significantly higher admission rate than the England average. http://www.cph.org.uk/publication/tiig- intentional-and-unintentional-childhood-injuries-within-greater-manchester-201112-to-201213/

In order to reduce injuries in children and its associated impacts across Tameside, local agencies need to understand which injuries are most widespread.

Injuries can be split into two distinct categories, those that are unintentional such as falls and those that are intentional such as assaults.

Tameside had the 5th highest rate of admissions for falls across Greater Manchester, with five out of 10 local authorities having a higher rate of attendance for falls than the Greater Manchester average.

The admission of a patient (child) from A&E gives an indication of the severity of the injury to a child. Fewer than 1 in 10 injuries among children from Greater Manchester were admitted (7%). However for Tameside this increases to 13% of attendances to admission to hospital, indicating that these injuries were more serious.

27 Categories of Death. National CDOP Form C

This form is used by the panel to categorise child deaths and provide consistency for all CDOPs in England and Wales

Name & description of category

1 Deliberately inflicted injury, abuse or neglect This 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, and 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, and 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.

28 8 Perinatal/neonatal event Death ultimately related to perinatal events, eg sequelae 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).