Derby City and County Child Death Overview Panel Annual Report 2017-2018

Alex Hawley (Acting Consultant in Public Health, City Council and Chair of CDOP) Sereena Raju (Information Analyst, Public Health, Derby City Council)

1 2 CDOP Annual report April 2017 – March 2018

Contents Preface ...... 4 The year in retrospect ...... 6 The panel’s meetings April 2017 to March 2018 ...... 6 Confidentiality ...... 9 Safe sleeping ...... 9 Sudden neonatal deaths in hospital ...... 11 Maternal obesity ...... 12 Smoking in pregnancy ...... 13 Update on nappy sacks ...... 14 Update on consanguinity ...... 15 Taking stock ...... 15 Looking forward ...... 16 Analysis of Case Data ...... 18 1.0 2017/18 data ...... 18 1.1 Modifiability ...... 23 2.0 2013/14 – 2017/18 data ...... 24 2.1 Trends over the five year period ...... 24 2.2 Cumulative patterns ...... 27 2.3 Modifiability ...... 40

3 Preface I am pleased to present our Child Death Overview Panel (CDOP) annual report for 2017- 2018. As always, the panel has gone about its work with great diligence and dedication, always adopting an objective but sensitive approach to such emotionally and professionally challenging subject matter, with undiminished zeal for learning and applying important lessons, to benefit and protect other (and future) Derbyshire children. It is worth restating Ofsted’s judgement of the work of the panel from its inspection of the Derby Safeguarding Children Board in early Spring of 2017, in which it found that the panel was doing “all that it can to ensure that awareness is raised in the local community in the hope of preventing further deaths.”

I certainly would like to take the opportunity I have in writing this preface to offer my personal thanks to everyone who has attended CDOP panels during the year, or who has contributed behind the scenes. I feel extremely privileged to have been the Chair of this panel for nearly two years, given the high calibre and dedication of all its members from across a wide range of disciplines. Thanks to everyone who has contributed Form Bs, compiled agendas, presented cases, taken minutes, followed up actions, engaged in discussion, or represented CDOP at other meetings.

During the year, some long-serving stalwarts of the panel have moved on, and I would therefore particularly like to register huge thanks and best wishes to DCI Malcolm Bibbings, Dr Helen Jacques, Sue Rucklidge, and Kathy Webster.

I am very confident that Juanita Murray, Kathy Webster’s successor as Designated Safeguarding Nurse in the north, and also my successor as incoming Chair, will benefit from the same level of commitment and support from her CDOP colleagues that I have enjoyed, and will successfully take the work of the panel forward. I would also like to extend my thanks to Michelina Racioppi, who will shortly be stepping down as Vice-Chair, and I am very grateful to Anne Hayes for stepping up to take on that role and so ensure that Public Health continues to have a strong voice in the work of the panel.

It is clear that there are some important challenges in the year ahead, as national guidance and local governance changes come into force. At the time of writing, we are still awaiting the publication of the final Child Death Review statutory guidance (updating the consultation version that was published in October 2017). In the meantime, however, July saw the publication of the new ‘Working Together’ guidance, which means that the clock is already ticking for agreeing our revised local safeguarding arrangements, including CDOP and other processes of child death review.

4 We also now know that the long-awaited and keenly anticipated National Child Mortality Database (NCMD) is now in development. NHS has commissioned the University of Bristol, in collaboration with University of Oxford, UCL Partners and QES to develop the NCMD, to which all CDOPs will eventually submit data for central analysis, with the expectation of deeper understanding of patterns and trends. The project is funded for four years from April 2018, with these key milestones expected:

Year 1: Develop and pilot the IT systems required to support data capture and create the central database structure Year 2: Commence national data collection and publish the outcomes from the pilot Year 3: Annual and Thematic Reports Year 4: Annual and Thematic Reports

To better enable such national analysis, it seems inevitable that this project will require some further standardisation across CDOPs in the way that components of reviews are currently interpreted.

In the meantime, we always endeavour to achieve thoroughness and consistency in the decisions we make in the panel and the way that this is recorded and coded, and to be constantly vigilant for any emerging local themes or trends, so that we can respond accordingly. A key component of that is the analysis we carry out every year and present in this report. I hope that you find it both informative and interesting, notwithstanding the grim nature of the topic .

If this report raises any further questions or you would like to make any comments please do not hesitate to contact Rachel Turley for additional information via [email protected]

I am indebted to Sereena Raju, Information Analyst in the Public Health Department at Derby City Council, for carrying out the analysis of CDOP data for this report, and setting this out so clearly not only for the last financial year (2017/18), and also for the last five years (2013/14 to 2017/18). Given the number of historic cases that have come to panel this year, I was keen to include this look-back analysis, and I am very grateful to Sereena for agreeing to take on this extra work. Her analysis begins on page 17.

Finally, I would like to offer one final personal vote of thanks to Rachel Turley. It has been a pleasure and a privilege to work closely with Rachel, and I am very grateful for her constant good humour and personal support at all times.

Alex Hawley, Acting Consultant in Public Health, Chair of Derby City and Derbyshire County Child Death Overview Panel

5 The year in retrospect

The panel’s meetings April 2017 to March 2018

The number of cases presented at each panel sitting are set out below, along with the number of representatives present at each meeting. Note that the August meeting was cancelled due to availability, and March was used as an additional neonatal panel meeting (neonatal panels shaded in blue, full CDOP panels in green), rather than a development session. In November, there were no Lead presenters available, meaning no cases could be presented, but the meeting went ahead as a development and communication session, with a focus on the consultation on ‘Working Together’, which concluded in December.

Cases Number presented attending

April 5 8

May 2 19

June 4 15

July 10 10

August Cancelled

September 6 17

October 12 10

November 15

December 6 20

January 13 16

February 5 19

March 14 16

Overall, the number of cases presented (not all were closed) to each neonatal panel tends to be larger, but usually with a slightly smaller attendance, owing to the greater medical focus of issues of concern, and perceived reduced need for wider partnership discussion. In total, 54 cases were presented to five neonatal panel sittings, while 23 cases were presented to five full CDOP panels. All the panel sessions last between three and three and a half hours, and also include sign-off of minutes, follow-up of actions, key communications from other panels and organisations, and discussions relating to developing the work of the panel and the wider child death review processes. Allowing for this, it is likely each neonatal case will

6 have occupied an average of about 15 minutes, and each non-neonatal case probably about 30 minutes of panel time.

We expect attendance as far as possible to represent our core membership organisations/professions, which currently are Derby City Council Children’s Services, Derbyshire County Council Children’s Services, Southern Derbyshire CCG, North Derbyshire CCG (also covering Erewash CCG and Hardwick CCG), , Chesterfield Royal Hospital NHS Foundation Trust, University Hospitals of Derby and Burton NHS Foundation Trust, Derbyshire Community Health Services NHS Foundation Trust, Derbyshire Healthcare NHS Foundation Trust, and Public Health on behalf of Derby City Council and Derbyshire County Council.

We keep our membership under review, and one of the successes of this year has been the regular attendance of a designated GP, which has proved very helpful for ensuring reviews are fully informed.

Attendance from core members has been good, with the main concern being Children’s Social Care from both City and County. Discussions about trying to improve this have been positive, despite obvious resource and capacity constraints, and give grounds for optimism about an improved level of attendance looking forward.

In total, some 45 people attended at least one CDOP panel meeting in 2017/18, and I would like to extend thanks to all those listed below who gave their time in this way to help us learn from tragedy with the ambition of preventing avoidable future child deaths.

Adrian Thorpe, Business Support, Derby City Council

Adrienne Williams, Team Manager, Children’s Services, Derbyshire County Council

Alex Hawley (Chair), Specialty Registrar in Public Health, Derby City Council

Beth Pascall, Paediatric Registrar (observer)

Carolyn Langrick, Maternity Matron, RDH (UHDB)

Colin Barker, Lay Representative

Emily Preston, Student Nurse (observer)

Emma Devitt, Bereavement Midwife, RDH (UHDB)

Emma Williams, Derbyshire Constabulary

DI Graham Prince, Derbyshire Constabulary

Dr Helen Jacques, Consultant Paediatrician, DHCFT

7 Jan Dawson, Head of Service, DCHS

Jane Haslam, Head of Midwifery, RDH (UHDB)

Dr Jenny Evennett, Designated Doctor for Safeguarding, RDH (UHDB)

Dr Jeremy Gibson, Named GP for Safeguarding

Dr John McIntyre, Consultant Neonatologist, RDH (UHDB)

Juanita Murray, Designated Nurse (observer)

Judy McCulloch, Specialist Midwife in Drugs & Alcohol (guest speaker)

Karen Barden, Acting Head of Child Protection, Children’s Services, Derbyshire County Council

Kate James, Senior Midwife, RDH (UHDB)

Kate Thorpe, School Nurse, DHCFT

Kathy Webster, Designated Nurse, NDCCG

Kayleigh Jennison, Paediatric Liaison Nurse, DHCFT

Dr Lizzie Starkey, Consultant Paediatrician, RDH (UHDB)

DCI Malcolm Bibbings, Derbyshire Constabulary

Dr Mengyan Lu, Foundation Doctor, placed at Derby City Public Health (guest speaker)

DCI Michael Cooper, Derbyshire Constabulary

Michelina Racioppi, Designated Nurse, SDCCG

Dr Nicola Medd, Consultant Paediatrician, CRH (CRHFT)

Dr Onajite Etuwewe, Consultant Paediatrician, DHCFT

DI Paul Bullock, Derbyshire Constabulary

Dr Peter Woodcock, Named GP for Safeguarding

Rachel Hunt, Student Health Visitor (observer)

Rachel Turley, CDOP Co-ordinator, DHCFT

Rebecca Siviter, Midwife in Drugs and Alcohol (guest speaker)

Rosie , Child Protection Manager, Children’s Services, Derby City Council

Sarah Fitzgerald, Named Nurse, DCHS

Shirley Adams, Minute-taker, Business Support, Derby City Council

Sinder Gill, Derbyshire Constabulary

Sue Earnshaw, Service Line Manager, Health Visiting, DHCFT

Sue Gittins, Named Nurse, CRH (CRHFT)

8 Sue Rucklidge, Bereavement Midwife, RDH (UHDB)

DI Toby Fawcett-Greaves, Derbyshire Constabulary

Vanessa Roberts, Healthy Child Programme Lead, Welbeck Road Medical Centre

Zoe Rudderforth, Safeguarding Advisor, DHCFT

Confidentiality

Every CDOP Panel meeting deals with personal information of the highest possible sensitivity, and always begins with everyone in attendance committing to a confidentiality declaration that appears at the top of every agenda:

CDOP Confidentiality Declaration

Information discussed by the group is strictly confidential and must not be disclosed to third parties without the agreement of the partners of the meeting. A clear distinction should be made between fact and opinion.

All agencies should ensure that the minutes are retained in a confidential and appropriately restricted manner.

The minutes will aim to reflect that all individuals who are discussed at these meetings should be treated fairly, with respect and without improper discrimination. All work undertaken at the meetings will be informed by a commitment to equal opportunities and effective practice issues in relation to race, gender, sexuality and disability.

With this in mind, this report will obviously avoid levels of detail that might risk disclosure, but will set out some of the themes that have emerged during the year, usually through a mixture of individual case reviews and wider discussion relating to current topics of interest or prompted by items of communication received by the panel from other CDOPs or other agencies with a concern for child safety.

Safe sleeping

In addition to reinforcing the advice regarding safe sleeping practices and factors in the household that increase the risk of SIDS (especially parental smoking and drinking), there has been considerable discussion arising from new products coming onto the market that make unsubstantiated claims for safety. Baby hammocks and poddle pods featured in the presentation to our CDOP seminar by RoSPA (as reported in last year’s annual report). In addition to these, we heard this year about sleep positioners, which featured in the national news in October 2017, when some UK retailers dropped such products in response to a statement from a US Regulator about the risk of suffocation that they pose.

9 Derby and Derbyshire CDOP does not support the use of any such products that create an additional risk of head-covering. We would seek to reinforce the message from the weight of available evidence, which is that the safest way for a baby to sleep is on a firm flat mattress, with no pillows, toys, cot bumpers or indeed sleep positioners.

We have also discussed concerns relating to home assembly of cots, especially when adjusting (e.g. the height of the mattress), reassembling a cot that has been stored flat, or assembling a cot purchased or acquired second hand. In such circumstances, concerns arise where manufacturer’s instructions may no longer be available and where key fixings may have been mislaid.

We are seeking advice from the RoSPA, CAPT and the Lullaby Trust regarding both trading standards applying to resale of such items, and a comprehensive guide for parents. In the meantime, our advice would always be to check for a cot that meets the British Standard for safety – BS EN 716. Additionally, check that the dimensions of the cot meet safety standards – at least 49.5cm deep; vertical bars with spacing of 4.5cm to 6.5cm. Do not use a second hand mattress, but purchase one new that meets BS 1877, and fits well with a gap of less than 4cm between the edge of the mattress and the sides of the cot.

Another area of concern with respect to safe sleeping is when a baby sleeps away from the parental home, especially in the home of grandparents. It is obviously far more difficult for our universal health visiting service to exert influence outside the family home. With this is mind our ‘Keeping Babies Safe’ sub-group has produced a leaflet specifically for grandparents.

Safe sleeping in the maternity ward setting has also been a topic of discussion, and we were pleased to hear of an intervention at Royal Derby Hospital, where an infographic has been developed and put on prominent display. This uses the acronym BASIC - BAby Safe In Cot, prior to new mothers getting some sleep. This looks like an excellent innovation that helps to keep babies safe in hospital and also instils good sleep behaviour at the earliest possible opportunity.

10

BASIC infographic. Reproduced with kind permission of Jane Haslam, Royal Derby Hospital

Sudden neonatal deaths in hospital

Related to concerns around safe sleeping in hospital is the incidence of deaths resulting from sudden unexpected postnatal collapse. The Panel has sought to understand what might lie behind such deaths, but the current expert view is that between 40% and 50% of such deaths remain unexplained. This is clearly an area where the national child mortality database is likely to prove of value in identifying patterns in such deaths evident across a national dataset. We have sought a better understanding of the national picture by seeking information from other CDOPs across the country, but this has not yet provided any insights.

According to a paper which analysed data from the UK via the British Paediatric Survey Unit (BPSU) [1], the incidence of such collapse within the first 12 hours of life is 5/100,000 term live births, with a mortality of 1/100,000 term live births, but other studies suggest the incidence of collapse could range between around 3/100,000 in the first 24 hours [2] and 27 per 100,000 within the first three days [3], and also that up to 50% of cases of collapse may result in death [4].

11 A number of risk factors are commonly identified in the literature, which include being a first- time mother; when initiating breastfeeding; when the baby is in a prone position; during skin- to-skin contact; cobedding, and mother and baby being left alone during first hours following birth [4], in addition to factors that might identify a baby at greater risk (e.g. low apgar score), or indeed where a mother is recovering from an exhausting labour. This is clearly an area where more understanding is required, but it already seems clear that surveillance and vigilance in the first hours after birth would be an important preventive strategy.

With some relation to this, the Panel was pleased to hear of Royal Derby Hospital’s innovation to ensure good temperature regulation, and to alert clinical staff (and parents) to be more vigilant where babies have higher risk, indicated by different coloured knitted hats.

Cindy Meijer, Risk Support Midwife with baby and coloured hats, and the ‘Goldilocks’ poster included in Royal Derby Hospital’s ‘Newborn Thermal Care Safety Bundle’. Reproduced with kind permission of Cindy Meijer and Jane Haslam, RDH

Maternal obesity

In April 2017, we received a question from Cumbria’s CDOP seeking examples from around the country where maternal obesity had been identified as a modifiable factor (i.e. a factor that could have been modified and may have led to a different outcome). This prompted discussion both about how routinely we would collect information about the BMI of the mother through our standard Form Bs, and also how confident we could be to attribute some level of contribution or causality to a mother’s weight. Cumbria was particularly interested in cases of prematurity.

The majority of neonatal deaths that CDOP reviews are preterm births (<37 weeks), and very often extremely preterm births (<28 weeks). In the literature there is an established association between maternal obesity and risk of prematurity, but since the numbers of premature births is low, the numbers where maternal obesity may have contributed are also

12 low. In the UK about 60,000 preterm babies are born each year, of which about 3000 are extremely premature, more than 50% of whom would now be expected to survive [5]. Mothers with BMI>40 may have three times the risk of delivering extremely prematurely [6], but such mothers only account for about 2% of pregnancies [7]. A quick rough calculation suggests overall, there may be around 100-120 additional extremely premature births associated with very high maternal BMI (>40) in the UK each year, and therefore perhaps 50 additional deaths. In Derbyshire, we might therefore only expect to see something like 7 or 8 such deaths over a ten year period.

Perhaps of more importance than engaging in discussion about levels of contribution for individual cases is simply to ensure that we collect the data in the first place, so that we can get more reliable population-level data regarding incidence and risk. We would therefore wish to see maternal BMI become a standard information item within the national child mortality database.

Smoking in pregnancy

The smoking habits of parents are routinely collected for CDOP review, and are often a source of much discussion in relation to both neonatal deaths and SIDS cases. The association between smoking in pregnancy and risks of prematurity, low birth weight and indeed SIDS are well established. Nevertheless, it is less than straightforward to identify smoking as a modifiable factor in an individual case, when basing this simply on population- level risk, especially when other potentially causal factors are identified. In effect, we know at a population level that a proportion of preterm births are likely to be attributable to smoking in pregnancy, but it does not always follow that where a neonatal death has occurred that the mother’s smoking habit contributed to the outcome.

The panel therefore tries to take a nuanced approach in looking at the specific circumstances of each case and attempting to identify where smoking is a modifiable factor that contributed to the death, or the slightly lesser implication of being a factor that contributed to vulnerability, or indeed is simply an incidental piece of information. This has often been a point of considerable debate and it is certainly not a consensus view of the panel that this approach is preferred over a more de facto approach that smoking should always be seen as contributory.

One potential difficulty that may arise from this approach is one of consistency – consistency over time, e.g. as more evidence emerges associating smoking with particular conditions or complications, and consistency with other CDOPs.

13 In April 2018, the Derby Telegraph ran a news item based exclusively on data reported in last year’s CDOP annual report, which had the headline, “Second-hand smoke played part in eight Derbyshire child deaths”, based on the fact that we had identified eight cases during the year where we had decided on the balance of probability that smoking by a parent or carer was considered to have contributed to vulnerability. Whilst it is pleasing that the local press has been moved to raise what is clearly a significant public health concern, their reporting of an exact figure in this way, based on the work of the CDOP panel, is effectively spurious, given the absence of a scientific method of classification.

As with maternal obesity, the more important factor for analytical purposes is really the fact that smoking habit data is collected, rather than how it was interpreted in individual cases. As work continues on developing the national child mortality database, some thought needs to be given to how this data is collected – e.g. whether number of cigarettes smoked needs to be recorded, or indeed if vaping habit needs now to be collected. Ultimately, we would also expect the national database to have a nationally consistent approach to how factors are categorised, and we would certainly appreciate at least some consistent guidance on this.

Strongly related to this is the use of other drugs by a parent, and some better understanding of the risks associated with smoking cannabis, for example, when compared with tobacco. We were fortunate in this respect in to receive a presentation to the January neonatal panel from Judy McCulloch, Specialist Midwife in Drugs & Alcohol. She was able to tell us that cannabis has been shown to be a risk for SIDS, and also told us about birth abnormalities and early miscarriages associated with use of M-CAT and Black Mamba, but overall confirmed that more research is needed in this area, particularly in respect of current trends for increasing use in pregnancy of cocaine, polypharmacy and new psychoactive substances, and indeed vaping.

Update on nappy sacks

Last year’s report described how Derby and Derbyshire CDOP continued to contribute to the national debate on the risk posed by nappy sacks, and in particular efforts co-ordinated by RoSPA to exert influence on retailers, suppliers and trading standards. During the year there have been some very encouraging developments. In September RoSPA and the British Retail Consortium published a guideline, advising on

14 warning labelling requirements for both back and front of packets, and seeking the development of a safety pictogram to be displayed at the point of extraction.

The guidelines are not prescriptive, but there appears to have been a positive response from the major retailers. In December, Morrisons announced they would become one of the first retailers to put warning labels onto the packaging, and since then many other major retailers have committed to adding warning labels to the front of packaging.

Update on consanguinity

In December and January, a series of four genetic literacy training sessions were delivered by Dr Aamra Darr to a total of 61 healthcare professionals, which received excellent feedback from delegates. The cost of the training was met by one-off funding obtained from NHS England, as this fitted well with their safeguarding priorities.

In February, CDOP heard from Dr Mengyan Lu, a second year Foundation doctor on rotation with Derby City Council’s Public Health team. Having benefited from the training, in early February she put it into immediate use, as she helped deliver a community workshop on cousin marriage on behalf of CDOP to a group of Pakistani muslim women resident in the Normanton area of Derby. The workshop included a presentation on some of the risks associated with cousin marriage, a lively discussion in which attendees were very willing to share personal experience and stories from within their kinship groups, and a discussion on producing a local information leaflet, based on the one used in Bradford. The consensus was that such a leaflet would be worthwhile and could be made available in community centres, mosques, GPs, etc.

Taking stock

During the year, both the CDOP Co-ordinator and the Lead Reviewers looked back through their records to identify any outstanding cases that had not yet come to the Panel for review. This uncovered a large number of quite historic cases (mostly neonatal) that still needed a Panel review. This prompted a one-off concerted effort to get up to date, and also a review of processes to ensure that a more rapid turnaround time could be assured and that there could not be a recurrence of such a backlog in the future.

CDOP is very grateful to all its reviewers for the additional effort required during the course of the year to get ourselves up to date. We decided to use our session in March, normally

15 reserved for a development workshop, as an additional neonatal panel to assist this process. Happily, by the end of the session in April 2018, our cases were largely up to date, and from this point on, we have agreed to include the date of notification for each case on the agenda, in order to continue to prioritise older cases for panel review.

Given the large number of historic cases that have been reviewed during the year, it is timely to include some revised time series analysis in the report, looking back over the last five years.

Another innovation this year to try to reduce potential for delay has been the use of a checklist for each case considered at review, to ensure that all the relevant information (e.g. Form Bs) has been received prior to the case being presented, and to ensure clarity about follow-up actions required, and whether a particular case has been kept open pending any such follow-up. This checklist is now included in the minutes for every case presented.

Looking forward One reason for getting ourselves up to date and for introducing new checks and processes is the ongoing changes to ‘Working Together’ and its associated changes in guidance for child death reviews. Amongst other things, the draft guidance set out an ambitious expectation that cases should be able to complete the entire review process within six months.

At the time of writing, we have the new ‘Working together to safeguard children’ guidance, published in July 2018, which includes a chapter specifically on statutory requirements for child death reviews and an outline of the responsibility of partners. However, final detailed guidance relating to child death reviews is still awaited.

Rather than waiting for this guidance to be published, we will be continuing to review our processes, based on the chapter in ‘Working together’ and the draft consultation version of the guidance published in October 2017. There are many considerations for us to work through: how we meet all the various stages of review in a timely fashion – immediate decision making and notifications, investigation and information gathering, the child death review meeting, and finally independent review by CDOP panel. Given that we will have no additional capacity, this will require some smart thinking about our processes and tools and how we share out responsibilities. In respect of responsibilities, we are aware of the need to provide the role of ‘Designated Doctor for child deaths’, which looks entirely new, but which will have to be accommodated within existing resources.

The draft guidance suggests that some child deaths may be best reviewed at a themed meeting, where there are a number of cases with a similar cause or group of causes. We

16 have routinely considered all our neonatal cases separately from other cases, largely for convenience, but have not yet intentionally grouped cases by theme. We are intending to trial this approach in November this year, when we will be reviewing a number of cases that broadly relate to adolescent mental health and behaviour, and will extend the membership of the panel to include people with particular relevant expertise. It is hoped that this will prove beneficial in respect of the discussion and lessons learnt. Any benefits of such an approach on an ongoing basis will need to be balanced against the potential delay that it introduces into the review process, if particular cases need to be held back for consideration at a themed meeting.

The new guidance doubtless presents a number of challenges, but CDOP has always had a very committed body of people behind it, who as Ofsted recognised do all that they “can to ensure that awareness is raised in the local community in the hope of preventing further deaths”.

17 Analysis of Case Data The analysis of data is divided into two sections. The first provides an overview of data from the latest year (2017/18). The second provides a cumulative analysis of the previous five years (2013/14 – 2017/18).

1.0 2017/18 data During 2017/18, 73 cases were reviewed by the panel1. These were assessed for modifiability and any relevant environmental, extrinsic, medical or personal factors that may have contributed to the child’s death.

Table 1 provides a breakdown of reviewed cases grouped by local authority of residence.

Table 1: Number and proportion of deaths reviewed grouped by local authority of residence

Local authority of Number of deaths Proportion of residence deaths Derby City 24 32.9% 9 12.3% 9 12.3% Erewash 8 11.0% 5 6.8% Chesterfield <5 * High Peak <5 * Glossop* <5 * North East Derbyshire <5 * Derbyshire County Total 43 58.9% No data <5 * East Staffordshire <5 * North West Leicestershire <5 * Sheffield <5 * Grand Total 73 100.0%

*Although is part of High Peak, the areas have been separated for the purposes of this report.

In the previous year, a marginally higher number of deaths were reported in the county than the city. Table 1 suggests that this difference has increased substantially in 2017/18.

1 This refers to cases closed during the year.

18 Table 2 provides an overview of the events reviewed by the panel.

Table 2: Summary of events reviewed by the panel

Derbyshire Derbyshire Event Derby city Derby city % county county %

Neonatal death (B2) 12 19 50.0% 44.2% No data (blank) 9 14 37.5% 32.6% Sudden unexpected death in infancy (B4) <5 5 * 11.6% Known life limiting condition (B3) <5 <5 * * Other <5 <5 * * Child death <5 <5 * * Road traffic collision (B5) <5 <5 * * Total 24 43 100.0% 100.0%

Across the city and county, neonatal deaths were the most common type of event reviewed by the panel. This was closely followed by cases in which no event type was recorded, which highlights the importance of data completeness.

Table 3 provides a summary of the category of deaths reviewed by the panel.

Table 3: City-County split of the category of deaths

City and City and Category of Derby Derbyshire Derby Derbyshire County County death city county city % county % total total % Perinatal/neonatal event 13 20 33 54.2% 46.5% 49.3% Chromosomal, genetic and congenital anomalies 5 9 14 20.8% 20.9% 20.9% Infection Sudden unexpected, unexplained death Malignancy No data Chronic medical <5 <5 * * * 29.9% condition Known life limiting condition Undetermined Trauma and other external factors Total 24 43 67 100.0% 100.0% 100.0%

19 Overall, perinatal/neonatal events were the most common type of event reviewed. Within the city, these comprised a marginally higher proportion of cases than those in the county.

Table 4 provides a breakdown of the reviewed deaths in the city and county grouped by age category.

Table 4: City-County split of reviewed deaths grouped by age category

Derbyshire Derbyshire Age group Derby city Derby city % county county % 0-27 days 18 27 * 62.8% 28-364 days 5 8 * 18.6% 1-4 years 5-9 years <5 8 * 18.6% 10-14 years 15-17 years Total * 43 100.0% 100.0%

Table 4 indicates a greater proportion of deaths amongst children who were under 28 days of age.

Table 5 provides an overview of the number and proportion of reviewed cases grouped by gender.

Table 5: Number and proportion of reviewed deaths grouped by gender

Proportion of 0-17 Number of Proportion of Gender population (mid- reviewed deaths reviewed deaths 2017) Male 38 53.5% 51.1% Female 33 46.5% 48.9% Grand Total 71 100.0% 100.0%

There were a marginally higher proportion of cases amongst males, which reflects the structure of the population.

20 Table 6 provides an ethnic breakdown of the number and proportion of reviewed cases.

Table 6: Number and proportion of reviewed cases grouped by ethnicity

Number of reviewed Percentage of Ethnic group cases reviewed cases White British 33 45.2% No data (blank) 23 31.5% Not stated 12 16.4% Pakistani <5 * Asian Other <5 * Mixed/White & Black Caribbean <5 * Indian <5 * Total 73 100.0%

The White British group was the most common ethnic category amongst reviewed cases with a recorded ethnic category (n=33; 45.2%). A robust analysis of ethnicity was not possible due to the absence of a recorded ethnic category across 23 cases.

Table 7 provides a summary of the location at the time of death across all reviewed cases in the year.

Table 7: Number and proportion of reviewed cases grouped by location

Number of Proportion of Location at the time of death reviewed cases reviewed cases Acute hospital neonatal unit 28 38.4% Acute hospital paediatric intensive care unit 12 16.4% Acute hospital Acute hospital other 6 8.2% Acute hospital paediatric ward <5 * Acute hospital emergency department <5 * Other hospital area 7 9.6% Home of normal residence 6 8.2% Other private residence <5 * Hospice <5 * No data (blank) <5 * Public place <5 * Total 73 100.0%

The majority of reviewed cases were of deaths that took place in an acute hospital.

21 The Indices of Multiple Deprivation (IMD) 2015 score provides a relative measure of deprivation within an area. Thus the higher the deprivation score, the more deprived the area. Public Health England provide adjusted IMD 2015 scores that align with the 2011 lower super output areas (LSOAs) in England: https://www.gov.uk/government/statistics/english-indices-of-deprivation-2015

The IMD scores for the LSOAs across Derbyshire were sorted from the most to the least deprived, before being divided into local deprivation quintiles. This was used to form a lookup for the IMD scores extracted within the dataset.

Table 8 provides a summary of the number and proportion of cases across each deprivation quintile.

Table 8: Number and proportion of reviewed cases grouped by local deprivation quintile

Local deprivation quintile Number of cases Proportion of cases 1 32 45.1% 2 12 16.9% 3 10 14.1% 4 7 9.9% 5 10 14.1% Total 71 100.0%

In 2017/18, almost half of the cases (n=32; 45.1%) were from the most deprived quintile.

Table 9 provides an overview of reviewed cases grouped by contributory factors.

Table 9: Reviewed cases grouped by contributory factors

Proportion of all Contributory factor Number of reviewed cases reviewed cases (73) Acute/sudden onset illness 61 83.6% Prior medical intervention 30 41.1% Smoking by parent/carer in household 21 28.8% Smoking by mother during pregnancy 20 27.4% Other chronic illness 17 23.3% Prior surgical intervention 12 16.4% Access to health care 8 11.0% Alcohol/substance use by a parent/carer 8 11.0% Domestic violence 6 8.2% Motor impairment 5 6.8% Sensory impairment 37 50.7% Housing issues

22 Other disability or impairment Emotional/behavioural/mental health condition in child Epilepsy Consanguinity Co-sleeping Learning disabilities Child abuse/neglect Bullying Gang/knife crime Poor parenting/supervision Asthma Allergies Total number of contributory factors 225

The most common reported contributory factor was acute/sudden onset illness. This was followed by prior medical intervention (n=30; 41.1%) and smoking by a parent/carer (n=21; 28.8%).

1.1 Modifiability

Table 10 provides a high-level summary of modifiability.

Table 10: Modifiability of reviewed cases

Proportion of Modifiability Number of cases cases No modifiable factors identified 59 83.1% Modifiable factors identified 12 16.9% Total 71 100.0%

Modifiable factors were identified in 12 of the cases that were reviewed (16.9%).

Table 11 provides a gender breakdown of the modifiability of the cases in 2017/18.

Table 11: Number and proportion of cases grouped by modifiability and gender

No modifiable Modifiable factors No modifiable Modifiable factors Gender factors identified identified factors identified % identified %

Female 25 6 43.9% 50.0% Male 32 6 56.1% 50.0% Total 57 12 100.0% 100.0%

23 There was an equal gender split between cases in which modifiable factors were identified.

Table 12 provides a breakdown of the cases grouped by modifiability and local deprivation quintile.

Table 12: Number and proportion of cases grouped by modifiability and local deprivation quintile

Local No modifiable Modifiable factors No modifiable Modifiable factors deprivation factors identified identified factors identified % identified % quintile

1 24 7 41.4% 58.0% 2 11 <5 19.0% * 3 7 <5 12.1% * 4 6 <5 10.3% * 5 10 <5 17.2% * Total 58 12 100.0% 100.0%

Despite the small numbers, table 12 suggests that the majority of cases in which modifiable factors were identified were associated with higher levels of deprivation.

2.0 2013/14 – 2017/18 data

2.1 Trends over the five year period

Between 2013/14 and 2017/18, 307 cases were reviewed by the panel.

Table 13 provides a summary of the number and proportion of cases each year split by broad age group due to the volume of low numbers within the smaller categories.

Table 13: Number and proportion of cases each year grouped by broad age category

1 and under 2-17 Year 1 and under 2-17 Total % in year % in year 2013-14 46 22 68 67.6% 32.4% 2014-15 36 18 54 66.7% 33.3% 2015-16 40 22 62 64.5% 35.5% 2016-17 33 17 50 66.0% 34.0% 2017-18 61 10 71 85.9% 14.1% Total 216 89 305* 70.8% 29.2%

24 *Cases without a valid date of birth or date of death were excluded from this age breakdown, which will mean that the total adds up to less than 307.

Overall, the majority of cases were based on children aged 1 and under (n=216; 70.8%). However, this has become increasingly skewed in the latest year (2017/18).

Figure 1 provides an overview of trends in the overall rate of cases, those aged 1 and under and 2-17.

Figure 1: Trends in the rate of cases per 1,000 between 2013/14 – 2017/18

Figure 1 reinforces the recent increase in the rate of cases amongst children aged 1 and under. However, it should be noted that the confidence intervals are relatively wide. Conversely, there has been a marginal decline in the rate of incidents in the latest year.

25 Figure 2 provides a gender breakdown of trends in the rate of cases over the five years.

Figure 2: Gender breakdown of trends in the rate of cases between 2013/14 – 2017/18

Between 2013/14 and 2015/16, the rate of deaths amongst males aged 0-17 was consistently higher than that of females. However, the magnitude of this difference appears to have reduced in the latest year. It should also be noted that across all years, the rate of male and female deaths are not significantly different from each other due to the wide confidence intervals.

26 2.2 Cumulative patterns

Table 14 provides a breakdown of reviewed cases grouped by local authority of residence.

Table 14: Number and proportion of deaths reviewed grouped by local authority of residence

Local authority of Number of deaths Proportion of residence deaths Derby City 109 35.5% Amber Valley 34 11.1% South Derbyshire 23 7.5% Erewash 22 7.2% Bolsover 20 6.5% Chesterfield 17 5.5% 16 5.2% High Peak 11 3.6% 10 3.3% Glossop <5 * Derbyshire County Total 156 50.8% North West Leicestershire <5 * East Staffordshire <5 * Sheffield <5 * No data 36 11.7% Total 307 100.0%

There was a markedly higher proportion of cases reviewed within the county than the city (50.8% and 35.5% respectively).

Crude rates of death per 1,000 were calculated for each ward that was affected by at least one incident. This was done by dividing the numerator by the mid-2013 – 2017 ward-level population count (from ONS), which was subsequently multiplied by 1000.

Figure 3 depicts the rate of deaths amongst children aged 1 and under across the five year period.

27 Figure 3: Crude rate of deaths per 1,000 in children aged 1 and under

© Crown Copyright and Database Rights Ordnance Survey 2018. License Number: 100024913

*A key of the labelled wards is available in appendix 1.

Figure 3 suggests that some areas of the county were affected by the highest rate of deaths, particularly Bolsover and North East Derbyshire. Barms (in High Peak) and Clifton and Bradley (in Derbyshire Dales) were affected by the highest rate of deaths (11.7 and 11.6 respectively). This was closely followed by Barlborough in Bolsover (11.5). Many wards within Derby city were affected by smaller, nonetheless concerning rates.

Figure 4 below provides a district-level breakdown of the rate of cases reviewed for children aged 1 and under.

28 Figure 4: Crude rate of reviewed deaths per 1,000 local authority-level population in children aged 1 and under

29 The highest rate of reviewed deaths were from Derby city (2.40), followed by Amber Valley (1.95) and Bolsover (1.72). However, the confidence intervals are relatively wide, which indicates some random variation in the data.

Figure 5 provides a ward-level breakdown of the rate of deaths amongst children aged 2-17 over the five year period.

Figure 5: Crude rate of deaths per 1,000 in children aged 2-17

© Crown Copyright and Database Rights Ordnance Survey 2018. License Number: 100024913

*A key of the labelled wards is available in appendix 2.

30 As echoed previously, there were wide variations in the rate of deaths amongst this age group across Derbyshire. The Ashover ward in North East Derbyshire had the highest rate of deaths amongst 2-17 year-olds (1.66). This was followed by Hatton in South Derbyshire (0.86) and Hulland in Derbyshire Dales (0.72).

Figure 6 below provides a district-level breakdown of the rate of cases reviewed for children aged 2-17.

31 Figure 6: Crude rate of reviewed deaths per 1,000 local authority-level population in children aged 2-17

32 Figure 6 demonstrates that the highest rate of reviewed deaths amongst children aged 2-17 were from Derby city (0.304). This was followed by Amber Valley (0.224) and Bolsover (0.216). However, these should also be interpreted with caution due to the relatively wide confidence intervals.

Table 15 provides a breakdown of the events reviewed by the panel over the five year period.

Table 15: Summary of events reviewed by the panel

Total (including Derby Derbyshire outside Derby Derbyshire Overall Event city county areas and city % county % % those with no data) Neonatal death (B2) 54 61 134 49.5% 38.4% 43.6% Known life limiting condition (B3) 17 21 45 15.6% 13.2% 14.7% No data 9 19 * 8.3% 11.9% * Other 8 19 * 7.3% 11.9% * Sudden unexpected death in infancy (B4) 8 21 34 7.3% 13.2% 11.1% Fire and burns (B7) 6 <5 * 5.5% * * Child death <5 <5 6 * * 2.0% Apparent homicide (B11) <5 <5 * * * * Road traffic collision (B5) <5 <5 * * * * Other non-intentional injury/accident/traum a (B9) <5 <5 5 * * 1.6% Drowning (B6) <5 <5 * * * * Apparent suicide (B12) <5 6 * * 3.8% * Grand Total 109 159 307 100.0% 100.0% 100.0%

Neonatal deaths were the most common type of event reviewed by the panel (n=134; 43.6%), followed by a known life limiting condition (n=45; 14.7%).

Table 16 provides a summary of the category of deaths reviewed. It reinforces the fact that the majority of cases stemmed from a perinatal/neonatal event.

33 Table 16: City-County split of the category of deaths

Total (including Derbyshire outside Derby Derbyshire Category of death Derby city Overall % county areas and city % county % those with no data) Perinatal/neonatal event 46 56 120 42.2% 35.2% 39.1% Chromosomal, genetic and congenital anomalies 23 26 56 21.1% 16.4% 18.2% Malignancy 8 13 * 7.3% 8.2% * Deliberately inflicted injury, abuse or neglect 7 <5 11 6.4% * 3.6% Infection 7 9 * 6.4% 5.7% * Sudden unexpected, unexplained death 5 13 * 4.6% 8.2% * Acute medical or surgical condition 5 8 * 4.6% 5.0% * Chronic medical condition <5 10 13 * 6.3% 4.2% Trauma and other external factors <5 6 * * 3.8% * Known life limiting condition <5 <5 * * * * No data <5 5 * * 3.1% * Undetermined <5 <5 * * * * Suicide or deliberate self-inflicted harm <5 7 * * 4.4% * Grand Total 109 159 307 100.0% 100.0% 100.0%

Perinatal/neonatal events were the most common category of death within the city and county. There were a marginally higher proportion of cases with chromosomal, genetic and congenital anomalies within the city.

Table 17 presents the number and proportion of reviewed deaths grouped by age category. It also includes the percentage of children in Derbyshire as a proportion of the 0-17 population of Derbyshire between mid-2013 – mid 2017 (ONS, 2014-2017).

34 Table 17: Number and proportion of reviewed deaths grouped by age category, and percentage of children as a proportion of the 0-17 population of Derbyshire between mid-2013 – mid-2017 (ONS, 2014-2017)

Percentage of all children in Derbyshire Percentage of reviewed as a proportion of 0-17 Age group Number of deaths deaths population 0-27 days 151 49.5% 5.3% 28-364 days 54 17.7% 1-4 years 30 9.8% 22.6% 5-9 years 21 6.9% 28.4% 10-14 years 25 8.2% 26.6% 15-17 years 24 7.9% 17.1% Total 305 100.0% 100.0%

Although children under 1 comprise the lowest percentage of the 0-17 population (5.3%), this group had the highest proportion of deaths (67.2%).

Table 18 provides a breakdown of the reviewed deaths in the city and county grouped by age category.

Table 18: City-County split of reviewed deaths grouped by age category

Derbyshire Derbyshire Age group Derby city Derby city % county county % 0-27 days 59 74 54.1% 46.5% 28-364 days 20 28 18.3% 17.6% 1-4 years 11 15 10.1% 9.4% 5-9 years 8 11 7.3% 6.9% 10-14 years 7 16 6.4% 10.1% 15-17 years <5 15 * 9.4% Total * 159 100.0% 100.0%

The highest proportion of reviewed deaths within the city and county were amongst children under 28 days old. The city was more disproportionately affected by these.

Table 19 provides an overview of the number and proportion of reviewed cases grouped by gender.

35 Table 19: Number and proportion of reviewed deaths grouped by gender

Proportion of 0-17 Number of Proportion of Gender population (mid- deaths reviewed cases 2013 – mid 2017) Male 176 58.9% 51.1% Female 123 41.1% 48.9% Total 299 100.0% 100.0%

Table 19 highlights a higher proportion of reviewed cases amongst males (n=176; 58.9%). This was not representative of the local population, for which there was a virtually equal gender split (mid-2013 – mid 2017; ONS).

Table 20 provides an ethnic breakdown of the number and proportion of reviewed cases.

Table 20: Number and proportion of reviewed cases grouped by ethnicity

Number of Percentage of Ethnic group deaths deaths White British 164 53.4% No data (blank) 73 23.8% Pakistani 17 5.5% White Other 15 4.9% Not stated 15 4.9% Other ethnic group 8 2.6% Indian 5 1.6% Asian Other <5 Mixed/White & Black Caribbean <5 Mixed/White & Black African <5 3.3% Chinese <5 Black African <5 Bangladeshi <5 Mixed/Other <5 Total 307 100.0%

Amongst reviewed cases with a recorded ethnic category, the White British group was the most common ethnic category. It should be noted that there were a significant number of cases without a recorded category for this field (n=73; 23.8%).

36 Table 21 provides a summary of the location at the time of death.

Table 21: Number and proportion of reviewed cases grouped by location

Number of Proportion of Location at the time of death deaths deaths Acute hospital neonatal unit 79 25.7% Acute hospital paediatric intensive care unit 58 18.9% Acute hospital other 27 8.8% Acute hospital Acute hospital emergency department 23 7.5% Acute hospital paediatric ward 11 3.6% Acute hospital unknown dept 6 2.0% Acute hospital adult intensive care unit <5 * Home of normal residence 47 15.3% Other hospital area 18 5.9% Hospice 14 4.6% Public place 9 2.9% Other private residence 6 2.0% No data (blank) 5 1.6% Abroad <5 * Total 307 100.0%

The majority of reviewed cases were linked with an acute hospital. This was recorded in a variety of sub-codes, with neonatal unit being the most common (n=79; 25.7%).

Table 22 provides an overview of the number and proportion of cases across each deprivation quintile.

Table 22: Number and proportion of reviewed cases grouped by local deprivation quintile

Local deprivation Number of Proportion of quintile deaths deaths 1 89 29.0% 2 60 19.5% 3 57 18.6% 4 30 9.8% 5 35 11.4% No data (blank) 36 11.7% Total 307 100.0%

Table 22 indicates that almost half of the cases stemmed from the two most deprived quintiles (n=149; 48.5%).

37 Table 23 provides a breakdown of cases where the child had surviving siblings.

Table 23: Number and proportion of cases where there were surviving siblings

Number of Proportion Surviving siblings cases of cases No data (blank) 258 84.0% Yes 42 13.7% No 7 2.3% Grand Total 307 100.0%

Across the majority of cases, no data was recorded for this field (n=258; 84%). Across 42 cases (13.7%), there were surviving siblings.

Table 24 provides an overview of cases where safeguarding issues had been identified.

Table 24: Number and proportion of cases where safeguarding issues were identified

Proportion of all Dimension Number of cases deaths Child or family known to social care 22 7.2% Child or family known to police 32 10.4% Child or family known to both social care and police 11 3.6%

Safeguarding issues were identified in a minority of cases. Across 11 cases (3.6%), serious concerns had been identified by both social care and the police.

Table 25 provides an overview of reviewed cases grouped by contributory factors.

38 Table 25: Reviewed cases grouped by contributory factors

Number of Proportion of all Contributory factor reviewed reviewed cases cases (307)

Acute/sudden onset illness 231 75.2% Prior medical intervention 90 29.3% Other chronic illness 80 26.1% Access to health care 59 19.2% Smoking by parent/carer in household 51 16.6% Prior surgical intervention 50 16.3% Smoking by mother during pregnancy 46 15.0% Motor impairment 37 12.1% Domestic violence 30 9.8% Learning disabilities 26 8.5% Alcohol/substance misuse by a parent/carer 23 7.5% Epilepsy 23 7.5% Sensory impairment 20 6.5% Housing issues 19 6.2% Emotional/behavioural/mental health condition in child 19 6.2% Poor parenting/supervision 19 6.2% Other disability or impairment 17 5.5% Child abuse/neglect 15 4.9% Consanguinity 13 4.2% Co-sleeping 13 4.2% Gang/knife crime 6 2.0% Asthma 6 2.0% Allergies 5 1.6% Bullying <5 * Alcohol/substance misuse by child <5 * Diabetes <5 * Pets/animal assault <5 * Total number of contributory factors 906

The most common factor across modifiable cases was acute/sudden onset illness (n=231; 75.2%), which is intrinsic to the child. This was followed by prior medical intervention (n=90; 29.3%) – an issue related to service provision.

39 2.3 Modifiability

Table 26 provides a high-level summary of modifiability. Across the majority of cases, no modifiable factors were identified. Within 43 of the reviewed cases, modifiable factors were identified.

Table 26: Modifiability of reviewed cases

Proportion of Modifiability Number of cases cases No modifiable factors identified 222 72.3% Modifiable factors identified 43 14.0% No data (blank) 35 11.4% Not known 7 2.3% Total 307 100.0%

Table 27 highlights a gender breakdown of the cases grouped by modifiability.

Table 27: Number and proportion of cases grouped by modifiability and gender

Modifiable No modifiable Modifiable No modifiable No data factors No data factors factors factors (blank) identified (blank) identified identified identified % Gender % Female 93 16 13 43.5% 37.2% 37.1% Male 121 27 22 56.5% 62.8% 62.9% Total 214 43 35 100.0% 100.0% 100.0%

A higher proportion of male than female cases involved modifiable factors (62.8% and 37.2% respectively). However, male patients comprised a greater proportion of cases overall.

Table 28 provides an age breakdown of the cases grouped by modifiability.

40 Table 28: Number and proportion of cases grouped by modifiability and age category

No No Modifiable Modifiable modifiable No data modifiable No data Age group factors factors factors (blank) factors (blank) % identified identified % identified identified % 0-27 days 120 10 21 54.3% 23.3% 61.8% 28-364 days 32 16 6 14.5% 37.2% 17.6% 1-4 years 23 <5 <5 10.4% * * 5-9 years 13 <5 <5 5.9% * * 10-14 years 16 6 <5 7.2% 14.0% * 15-17 years 17 5 <5 7.7% 11.6% * Total 221 43 34 100.0% 100.0% 100.0%

In the majority of cases where modifiable factors were identified, the child was less than 1 year of age. This was followed by the 10-14 and 15-17 age categories.

Table 29 provides a breakdown of the cases grouped by local deprivation quintile and modifiability.

Table 29: Number and proportion of cases grouped by modifiability and local deprivation quintile

No No modifiable Modifiable modifiable Modifiable Local deprivation factors factors No data factors factors No data quintile identified identified (blank) identified % identified % (blank) % 1 56 14 12 25.2% 32.6% 34.3% 2 46 9 5 20.7% 20.9% 14.3% 3 38 11 8 17.1% 25.6% 22.9% 4 22 <5 5 9.9% * 14.3% 5 30 <5 <5 13.5% * * Insufficient data (no postcode) 30 <5 <5 13.5% * * Total 222 43 35 100.0% 100.0% 100.0%

Table 29 suggests that the majority of cases with modifiable factors were linked with higher levels of deprivation.

Tables 30 and 31 provide an overview of the number and proportion of cases grouped by modifiability and location of death.

41 Tables 30 and 31: Number and proportion of cases grouped by modifiability and location of death

No modifiable Modifiable Location at the time of death factors factors identified identified Acute hospital neonatal unit 65 <5 Acute hospital paediatric intensive care unit 47 6 Acute hospital other 20 <5 Acute hospital Acute hospital emergency department 13 8 Acute hospital paediatric ward 9 <5 Acute hospital unknown dept 5 <5 Acute hospital adult intensive care unit <5 <5 Home of normal residence 24 14 Other hospital area 16 <5 Hospice 10 <5 Public place <5 <5 Other private residence <5 <5 No data (blank) 5 <5 Abroad <5 <5 Total 222 43

No modifiable Modifiable Location at the time of death factors factors identified identified Acute hospital neonatal unit 29.3% * Acute hospital paediatric intensive care unit 21.2% 14.0% Acute hospital other 9.0% * Acute hospital Acute hospital emergency department 5.9% 18.6% Acute hospital paediatric ward 4.1% * Acute hospital unknown dept 2.3% * Acute hospital adult intensive care unit * * Home of normal residence 10.8% 32.6% Other hospital area 7.2% * Hospice 4.5% * Public place * * Other private residence * * No data (blank) 2.3% * Abroad * * Total 100.0% 100.0%

Tables 30 and 31 suggest that the majority of incidents with no modifiable factors arose in an acute hospital. The majority of cases in which modifiable factors were identified took place in the home of normal residence (n=14; 32.6%).

42 Table 32 provides an overview of the number and proportion of cases grouped by modifiability and safeguarding issues.

Table 32: Number and proportion of cases grouped by modifiability and safeguarding issues

No modifiable Modifiable factors No factors identified Modifiable identified (as a modifiable (as a proportion of Dimension factors proportion of cases factors cases with no identified with modifiable identified modifiable factors factors identified) identified) Child or family known to social care 13 6 5.9% 14.0% Child or family known to police 18 11 8.1% 25.6% Child or family known to both social care and police <5 5 * 11.6%

Table 32 suggests that there were a higher proportion of children with safeguarding issues amongst cases in which modifiable factors were identified.

43 Appendix 1: Key alongside figure 3: Crude rate of deaths per 1,000 in children aged 1 and under

Number Ward code Ward name Local authority Rate per 1,000 1 E05001043 Broomhill Sheffield 1.1 2 E05001767 Abbey 4.8 3 E05001768 Allestree 0.8 4 E05001769 Alvaston 2.6 5 E05001770 Arboretum 3.4 6 E05001771 Blagreaves 3.3 7 E05001772 Boulton 1.1 8 E05001773 Chaddesden 1.3 9 E05001774 Chellaston 1.6 10 E05001775 Darley Derby 2.0 11 E05001776 Derwent 0.4 12 E05001777 Littleover 1.9 13 E05001778 Mackworth 2.0 14 E05001779 Mickleover 2.1 15 E05001780 Normanton 3.2 16 E05001781 Oakwood 2.4 17 E05001782 Sinfin 3.4 18 E05001783 Spondon 1.5 19 E05003280 1.2 20 E05003282 Central 3.8 21 E05003283 Belper East 3.3 22 E05003286 Codnor and Waingroves 7.4 23 E05003290 and Loscoe 5.8 Amber Valley 24 E05003292 Heanor West 1.4 25 E05003293 Ironville and Riddings 5.6 26 E05003295 Langley Mill and Aldercar 3.9 27 E05003297 Ripley and Marehay 3.4 28 E05003299 Somercotes 1.2 29 E05003303 Barlborough 11.5 30 E05003306 Bolsover South 2.8 31 E05003310 Elmton-with-Creswell 1.3 32 E05003311 Pinxton 2.4 33 E05003314 East 5.1 34 E05003315 Shirebrook Langwith 4.6 Bolsover 35 E05003316 Shirebrook North West 3.0 36 E05003317 Shirebrook South East 6.2 37 E05003318 Shirebrook South West 2.9 38 E05003320 South Normanton West 1.3 39 E05003321 Tibshelf 1.7 40 E05003322 Whitwell 2.7 41 E05003324 Brimington North 5.0 42 E05003326 Brockwell 1.5 43 E05003327 Dunston Chesterfield 1.5 44 E05003333 Lowgates and Woodthorpe 2.1 45 E05003334 Middlecroft and Poolsbrook 1.4

44 Number Ward code Ward name Local authority Rate per 1,000 46 E05003335 Moor 2.5 47 E05003338 St. Helen's 3.7 48 E05003339 St. Leonard's 1.1 49 E05003347 Calver 9.2 50 E05003350 Clifton and Bradley 11.6 51 E05003351 Derbyshire Dales 3.6 52 E05003360 Matlock All Saints 4.4 53 E05003366 2.0 54 E05003369 Cotmanhay 1.7 55 E05003370 Derby Road East 1.1 56 E05003371 Derby Road West 3.5 57 E05003372 Draycott 2.3 58 E05003373 Hallam Fields 1.5 59 E05003374 Central 1.6 60 E05003375 Ilkeston North 1.6 61 E05003376 Kirk Hallam Erewash 1.2 62 E05003378 Little Hallam 2.3 63 E05003379 Central 1.4 64 E05003380 Road 1.0 65 E05003382 Old Park 4.2 66 E05003383 North 1.8 West Hallam and Dale 67 E05003387 Abbey 2.3 68 E05003389 Barms 11.7 69 E05003392 Central 8.7 70 E05003395 Corbar 6.1 High Peak 71 E05003408 Padfield 2.6 72 E05003413 Temple 8.9 73 E05003416 Whitfield 3.5 74 E05003427 Eckington South 2.6 75 E05003429 1.8 76 E05003432 West 1.9 North East Derbyshire 77 E05003435 Renishaw 10.0 78 E05003436 Ridgeway and Marsh Lane 10.3 79 E05003438 Sutton 3.1 80 E05005511 Appleby North West 4.6 81 E05005523 Measham South Leicestershire 2.0 82 E05006931 Stapenhill East Staffordshire 2.0 83 E05008520 Belper South 1.4 84 E05008521 Duffield Amber Valley 2.9 85 E05008809 Aston 1.8 86 E05008810 Church Gresley 2.2 87 E05008811 Etwall 2.0 88 E05008812 Hatton 10.5 89 E05008813 Hilton South Derbyshire 0.8 90 E05008814 Linton 1.9 91 E05008816 Midway 1.0 92 E05008820 Stenson 4.6 93 E05008822 Willington and Findern 2.5

45 Appendix 2: Key alongside figure 5: Crude rate of deaths per 1,000 in children aged 2- 17

Number Ward code Ward name Local authority Rate per 1,000 1 E05001767 Abbey 0.31 2 E05001770 Arboretum 0.05 3 E05001771 Blagreaves 0.15 4 E05001773 Chaddesden 0.07 Derby 5 E05001777 Littleover 0.24 6 E05001778 Mackworth 0.16 7 E05001780 Normanton 0.12 8 E05001782 Sinfin 0.42 9 E05003281 Alport 0.55 10 E05003282 Belper Central 0.67 11 E05003284 Belper North 0.30 Amber Valley 12 E05003293 Ironville and Riddings 0.20 13 E05003295 Langley Mill and Aldercar 0.19 14 E05003299 Somercotes 0.16 15 E05003309 Clowne South 0.35 16 E05003311 Pinxton 0.30 Bolsover 17 E05003321 Tibshelf 0.41 18 E05003322 Whitwell 0.33 Hollingwood and 19 E05003329 Inkersall 0.13 Lowgates and 20 E05003333 Woodthorpe Chesterfield 0.21 21 E05003337 Rother 0.34 22 E05003338 St. Helen's 0.23 23 E05003339 St. Leonard's 0.16 24 E05003351 Darley Dale 0.21 25 E05003356 Hulland Derbyshire Dales 0.72 26 E05003366 Wirksworth 0.20 27 E05003369 Cotmanhay 0.26 28 E05003375 Ilkeston North 0.22 29 E05003376 Kirk Hallam Erewash 0.34 30 E05003385 Sawley 0.17 31 E05003388 Wilsthorpe 0.13 32 E05003391 Burbage 0.66 33 E05003401 Hayfield 0.54 High Peak 34 E05003407 Old Glossop 0.21 35 E05003415 0.35 36 E05003417 Ashover 1.66 37 E05003420 North 0.21 38 E05003426 Eckington North 0.38 North East Derbyshire 39 E05003429 Grassmoor 0.27 40 E05003433 North Wingfield Central 0.44 41 E05003440 Unstone 0.64 North West 42 E05005523 Measham South Leicestershire 0.17 Shipley Park, Horsley 43 E05008524 and Horsley Woodhouse Amber Valley 0.42

46 Number Ward code Ward name Local authority Rate per 1,000 44 E05008809 Aston 0.33 45 E05008810 Church Gresley 0.11 46 E05008812 Hatton 0.86 South Derbyshire 47 E05008813 Hilton 0.09 48 E05008816 Midway 0.12 49 E05008817 Newhall and Stanton 0.12

47