Bedford Borough, Central Bedfordshire and Luton Child Death Overview Process Panel
Annual Report
1 April 2019 – 31 March 2020
Contents
Description Page Number Executive Summary 3 1. Background and Functions 6 2. The Principles and Process 7 3. Bedfordshire data in comparison with National Data 9 - Reported deaths and cases reviewed 13 - Duration of reviews. - Category of death. - Modifiable factors. - Age, Gender and Ethnicity. 4. Learning from the reviews and actions taken 19 Areas for Development and future plans 20
Page 2 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician
Executive Summary
The Children Act 2004 provided the legislative framework for the original Child Death Overview Panels (CDOPs), which in Bedfordshire & Luton was established as one panel in 2008,and was supported by well-established local child death review arrangements and reporting arrangements into the Local Safeguarding Children Boards (LSCBs). However, with new legislation, the Children and Social Work Act 2017 has resulted in amendments to the Children Act 2004 and subsequently changes to the statutory responsibilities for child death reviews. The responsibility for ensuring child death reviews are carried out is now held by the “child death review partners”(CDR) who, in relation to a local authority area in England, are defined as the local authority (LA) for that area and any clinical commissioning groups (CCG) operating in the LA area. Since September 2019, the CDR partners had a duty to make arrangements, to carry out child death reviews and these arrangements were to result in the establishment of a Child Death Overview Panel (CDOP), or equivalent, to review the deaths of all children normally resident in the relevant local authority area and, if they considered it appropriate, the deaths in that area of non-resident children. The Bedfordshire and Luton CDOP covers a geographical footprint which is typically notified of approximately 60 child deaths per year. In order to comply with the statutory guidance, the CDR partners for the following localities agreed to continue with one CDOP to cover their combined geographical footprint: Bedfordshire & Luton. However, during the period for this report, there were a total of 50 child deaths reported across Bedfordshire and Luton. This was a decrease in numbers from 2018-19, where 71 child deaths were reported. Operational policies and terms of reference have been agreed by partners to address the statutory changes. These new arrangements are available to view on the safeguarding partner websites (formerly LSCBs) in Luton, Central Bedfordshire and Bedford Borough. This is the 1st Annual Report under the new statutory arrangements of the Bedford Borough, Central Bedfordshire and Luton Child Death Overview Panel (CDOP). It gives a summary of the deaths reported to the Panel as well as those reviewed by the Panel during 2019-2020, an analysis of the data and emerging themes. Due to low numbers of child deaths during this period, it needs to be noted that figures which may look significant may not be statistically significant or meaningful. During the period April 2019 until March 2020 there were 50 child deaths reported across Bedfordshire. This was made up of 9 (18%) child deaths in Bedford Borough, 29 (58%) in Luton and 12 (24%) in Central Bedfordshire. In 2018-19 there were 71 child deaths. This is a decrease of 29.5%. Unexpected deaths accounted for 19 out of 50 (38%) of the total deaths reported in 2019-20. 35 of the deaths were of infants under one year of age. During the period 1st April 2019 to 31st March 2020, the Panel met on 6 occasions and completed full reviews on 47 children residing in Bedford Borough, Central Bedfordshire and Luton. This was an increase of 21.28% from the Annual Report of 2018-19, where 37 cases reviews were completed. These cases included children who died between 2016 and 2019. There can be a delay in reviewing some cases due to other processes taking place such as coronial inquests, criminal investigations and toxicology reports.
Page 3 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician
Modifiable factors were identified in 29% (14/47) of cases; this is lower than last year where modifiable factors were found in 32% of cases reviewed at Panel. Similar to previous years, the modifiable factors identified included service provision, consanguinity and maternal BMI. Service provision featured as a modifiable factor in 6 of all cases reviewed, BMI in 4 of all the deaths reviewed and consanguinity in 4 deaths reviewed.
Due to the small numbers it is not possible to comment on the physical environment where modifiable factors were identified. In addition, under the new statutory arrangements which outlined that some child deaths may be best reviewed at a themed meeting, 2 Neonatal Themed Panel meetings were held during 2019-20. Both themed panel meetings were for neonatal deaths and led by the Designated Doctors for Child Deaths. The panel included Neonatologists, Obstetricians and Midwives. A themed meeting is one where CDR partners arrange for a single CDOP to collectively review child deaths from a cause or group of causes. Such arrangements allow appropriate professional experts to be present at the panel to inform discussions, and/or allow easier identification of themes when the number of deaths from a cause is small. The number of deaths closed under the category of Perinatal/Neonatal events (Category 8) was 14, (30% of all cases), compared to 11 cases in 2018-19. 11 (78.5%) of these 14 deaths related to extreme prematurity. This is a similar figure to the national data.
Changes to CDOP and National Data Collection Under the new statutory arrangements, the collation and sharing of the learning from reviews is now managed by the National Child Mortality Database (NCMD).This process ensures that information from the child death review process is systematically captured to enable local learning, to identify learning at national level and inform policy and practice.
The NCMD drives improvement in the quality of health and social care for children and collects a minimum dataset from the Child Death Overview Panel (CDOP) reviews of all child deaths in England and is the repository of data relating to all children’s deaths (up to age of 18 years), in England. It became operational in 2019 with the aim to enable more detailed analysis and interpretation of all data arising from the child death review process, ensuring that lessons are learned following a child’s death, that learning is widely shared and that actions are taken locally and nationally to reduce child mortality and help reduce the risk of future child deaths.
Bedfordshire and Luton CDOP provide standardised data on each child death to inform this national process and is closely aligned to Milton Keynes CDOP for shared learning purposes and both CDOP areas have joint eCDOP arrangements in place.
Key Areas of Note from 2019-20: Page 4 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician
1. The number of deaths has varied over the last few years. There was a decrease in the number of child deaths across Bedfordshire and Luton from 71 in 2018-19 to 50 in 2019-20. This equates to a 29.5% reduction in reported child deaths, although as the numbers are relatively small it is not possible to state if this is a genuine down ward trend.
2. The CDOP has reviewed and closed 47 cases this year which is 10 cases more than in the previous year. This is for a variety of reasons including the introduction of themed panels where cases are reviewed as a collective and under the new arrangements information being more readily available to inform the CDOP panel process.
3. Bedfordshire and Luton CDOP had a decrease in the number of modifiable factors being identified 14/47 (29%) for 2019-20, compared to 32% in 2018-19 and 39% in 2017-18. Nationally 31% have been identified with modifiable factors. https://www.ncmd.info/2020/11/12/cdr-data-2019-20/
4. A lower proportion 9/47 (19%) of cases reviewed at Panel were reviewed within 6 months of the child’s death; this is notably lower than in last year (43%) and is below the national average (32%).
5. Chromosomal, Genetic and Congenital anomalies (Category 7) made up 18/47 (38%) of the reviewed cases. This is an increase on the previous 2 years where 32% of cases in 2018-19 and 30% of cases in 2017-18 closed under this category.
Death Notified in 2019-20
In Central Bedfordshire there were 12 deaths; a decrease from 2018-19 when there were 20 deaths. There was an increase in unexpected deaths (3/12) compared to (1/20) in 2018-19 and (3/16) in 2017-18. Ward level data depicts a varied spread of child deaths.
In Bedford Borough there were 9 deaths; a decrease this year as in the previous year 2018-19 there were 21 deaths. There was a decreased in unexpected deaths (2/9) compared to (8/21) in 2018-19 and (7/12) in 2017-18.
In Luton there were 29 deaths compared to 28 deaths in the previous year. The proportion of unexpected deaths has been similar in recent years (6/29) in 2019-20 compared to (7/28) 2018-19 and slightly lower (3/27) in 2017-18.
Whilst it would be helpful to have a breakdown of deaths in ward areas linked to Indices of Multiple Deprivation, numbers are too low in this period to report.
Page 5 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician
1. Background and Functions The child death review process covers all child deaths. A child is defined in the Act as a person under 18 years of age. A child death review must be carried out for all children regardless of the cause of death. This includes the death of any live-born baby where a death certificate has been issued. If the birth is not attended by a healthcare professional, child death review partners may carry out initial enquiries to determine whether or not the baby was born alive. If these enquiries determine that the baby was born alive, the death must be reviewed.
For the avoidance of doubt, it does not include stillbirths, late foetal loss, or terminations of pregnancy (of any gestation) carried out within the law. Stillbirth is defined as a baby born without signs of life after 24 weeks gestation, late foetal loss as a pregnancy that ends without signs of life before 24 weeks gestation.
Cases where there is a live birth after a planned termination of pregnancy carried out within the law are not subject to a child death review. The Bedfordshire and Luton CDOP reviewed 47 child deaths in 2019-2020 of children usually resident in the area. eCDOP
The Bedfordshire and Luton CDOP partners have purchased the software package known as eCDOP, to support the CDR case management and reporting process. The system is now being used to manage 82% of all cases reviewed in England.
The eCDOP system uses the statutory forms and processes from the Working Together 2018 guidance, and assists safeguarding teams to ensure compliance. The intuitive system is now renowned for improving efficiency throughout multi-agency information sharing processes, having proven to significantly reduce administration time for information collation from two days to just two hours.
The information sharing collaborative approach between multi-agency partners offers the vital opportunity to derive learning and apply important changes to practices and policies. The eCDOP system automatically transfers data at each relevant stage of the process into the National Child Mortality Database (NCMD). This information is then used to analyse data nationally in order to improve learning and implement strategic improvements in health care for children in England with the overall goal to reduce child mortality.
2. The Principles and Process Page 6 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician
The principles underlying the overview of all child deaths are:
Every child’s death is a tragedy. Learning lessons including referring cases for in depth review/scrutiny such as Child Safeguarding Practice Reviews (CSPR). Joint Agency working and informing service provision, to ensure bereaved families are supported. Positive action to safeguard and promote the welfare of children.
The CDOP reviews all deaths for children who are born in their area and are under the age of 18. The panel receives anonymised information in the form of an Analysis Form (previously referred to as Form C) from the local Child Death Review Meetings (CDRM).
Where a child dies unexpectedly, a Joint Agency Response is triggered. Joint Agency Response is defined as a coordinated multi-agency response (including on-call health professional, police investigator, duty social worker)and should be triggered if a child’s death:
is or could be due to external causes is sudden and there is no immediately apparent cause (including SUDI/C); occurs in custody, or where the child was detained under the Mental Health Act where the initial circumstances raise any suspicions that the death may not have been natural or in the case of a stillbirth where no healthcare professional was in attendance. Following a child death, a CDRM will be held by those involved in the care of the child prior to their death which may take the form of a Mortality Review meeting or, a Multiagency meeting following a JAR. The CDRM will complete an analysis form which is subsequently reviewed by the Child Death Overview Panel. The process of reviewing all child deaths is outlined in the chart below.
Page 7 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician
3. Bedfordshire and Luton Data in Comparison with National Data
Page 8 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician
We are comparing our local data against National Child Mortality Database annual report for 2019-20.
The National Picture (Year ending March 2020)
2,738 reviews completed by Child Death Overview Panels in the year ending March 2020. This is a decrease of 512 (16%) in comparison to the previous reporting year (3,250). Bedfordshire CDOP has increased the number of cases reviewed in 2019-20 (47) compared to 2018-19 (37).
31% nationally of child death reviews identified modifiable factors, a slight increase from 28% last year. Bedfordshire CDOP identified (29%) of modifiable factors in 2019-20, although this is a reduction from previous year (32%). Further detail can be found in the Modifiable Factors section of this report.
851 reviews (31%) nationally recorded a primary category of “Perinatal/neonatal event”, and a further 674 reviews (25%) recorded a primary category of “Chromosomal, genetic and congenital anomalies”. These two categories combined represent over half (56%) of reviews completed.
16 reviews (32%) locally of deaths were due to a “Perinatal/neonatal event” within Bedfordshire and Luton and 18 reviews (38%) were recorded with the primary category of “Chromosomal, genetic and congenital anomalies”. These two categories represent 34/47 deaths reviewed.
1106 reviews (41%) nationally occurred in the neonatal period (0-27 days) and a further 591 (22%) deaths were within the 28-364 days age group. Together, deaths where the child was aged less than 1 presented 63% of child deaths reviewed during 2019-20.
35 reviews (74%) were for children under one year old in the year ending March 2020; this is consistent with the national picture.
Mortality Rates in Bedfordshire and Luton
Page 9 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician
The data for child mortality rates up to the age 17 years have not been updated since 2016. However, data has been updated to 2015 - 2017 pertaining to infant mortality rates as detailed below. This is particularly relevant as over 50% of the deaths reviewed across Bedfordshire and Luton are of those less than 1 year old. IMR for three local authorities are detailed below with comparisons to statistical neighbours and England as a whole. Bedford Borough
Infant mortality rates 2017 - Infant mortality rates 2014 - 2016 Bedford Borough & it's CSSNBT Bedford Borough & it's CSSNBT Statistical neighbours (deaths per Statistical neighbours (deaths per 1,000 live births) 1,000 live births)
England 3.9 3.9 Bedford 4.1 4.1
Derby 6.2 6
Milton Keynes 4.5 4.4 Sheffield 4.8 5.2
Leeds 4.2 4.4 Hertfordshire 2.8 2.8
Warwickshire 4.2 4.7 Kent 3.8 3.5
Northamptonshire 4.5 4.3
Swindon 3.4 3
Similar Worse
Better
Central Bedfordshire Page 10 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician
Infant mortality rates 2015- 2017 Infant mortality rates 2014 - 2016 Central Bedfordshire & it's Central Bedfordshire & it's CSSNBT CSSNBT Statistical neighbours Statistical neighbours (deaths per (deaths per 1,000 live births) 1,000 live births)
England 3.9 3.9
Central Bedfordshire 2.6 2.2
Hampshire 3.5 3 Warwickshire 4.2 4.7
Essex 3.1 3.3 Leicestershire 3.7 3.9
South Gloucestershire 3.5 3.5
Worcestershire 4.1 4.9 Cheshire East 3.4 3.9
West Sussex 2.7 3.1 Bracknell Forest 2.8 1.6
West Berkshire 4.2 3.7
Similar
Worse Better
Luton
Page 11 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician
Infant mortality rates 2014 - 2016 Infant mortality rates 2015-2017 Luton & it's CSSNBT Statistical Luton & it's CSSNBT Statistical neighbours (deaths per 1,000 live neighbours (deaths per 1,000 live births) births)
England 3.9 3.9
Luton 5.6 5.4 Birmingham 7.8 7.9
Sandwell 6.5 5.8
Slough 5.3 4.2 Bradford 5.8 5.9
Walsall 6.2 7.1 Enfield 3.2 3.2
Hillingdon 2.9 2 Derby 6.2 6
Wolverhampton 5.8 5.6
Oldham 5.9 6.2
Similar Worse
Better
Refs: https://fingertips.phe.org.uk/profile/child-health- profiles/data#page/3/gid/1938133232/pat/6/par/E12000006/ati/202/are/E10000015/iid/92196/age/2 /sex/4
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/dataset s/deathsregisteredbyareaofusualresidenceenglandandwales It is important to note that the IMR in the UK is relatively high compared to our European counter parts. The UK’s IMR is 23rd highest out of 25 Nations. https://stateofchildhealth.rcpch.ac.uk/ Reported Deaths and Cases Reviewed
Page 12 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician
Reported Child Deaths The number of deaths in each LSCB area over the past 5 years is shown in Table 1. This shows an overall decrease in child deaths this year. Luton has seen a decrease of 2; Central Bedfordshire of 8 and Bedford Borough of 10. Both Central Bedfordshire and Bedford Borough have had the lowest number of deaths reported this year compared to any of the previous 4 years. Table 1: Deaths reported 2014/15 – 2019/20
LSCB Area 2015 - 2016 - 2017- 2018 - 2019 - Total by Average 2016 2017 2018 2019 2020 Local 2015/2020 Authority
Luton 31 28 25 30 29 143 28.6
Central 16 14 17 20 12 79 15.6 Bedfordshire
Bedford Borough 13 12 15 21 9 70 14.2
Total 60 54 57 71 50 292 58.4
During the period April 2019 until March 2020 there were 50 deaths reported across Bedfordshire; there has been a decrease in number of notified deaths this year and it is not possible to determine whether this is part of a trend or within natural variation.
Deaths reviewed by CDOP in 2019-2020 Page 13 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician
The CDOP panel met on 6 occasions during this period and completed full reviews on 47 children residing in Bedford Borough, Central Bedfordshire and Luton. This was an increase of 21.28% from the Annual Report of 2018-19 where 37 case reviews were completed. The following sections relate to reviewed deaths.
Not all of the deaths reviewed occurred in 2019-2020, some will have occurred in the previous or earlier years. There is generally a gap of several months between a reported death and the final review at the panel to ensure that all relevant information is available for the review. CDOP is unable to review a death until all other processes have been completed, for example if there is a Child Safeguarding Practice Review or a Coroner’s Inquest.
45% of child deaths reviewed in 2019-20 were completed within 12 months of the child’s death. This is a decrease from the previous year (67%) and less than the National Percentage of 76%. This was due to a number of factors, including a backlog of cases dating back to 2016. A breakdown of the duration of reviews is shown in Figure 1.
Figure 1: Duration of Reviews
Duration of Reviews
Less than 6 months 6-12 Months 12 months +
20%
55% 25%
Page 14 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician
CDOP plans to increase the number of cases reviewed at panel and to hold further neonatal themed panels to improve the timeliness of reviews.
Primary category of death in completed reviews
The child death review process aims to categorise the death and identify any modifiable factors for each child that dies and establish whether any lessons can be learned at a local or national level.
Table 2 shows that the highest proportion of cases in 2019-20 were under the Chromosomal, Genetic and Congenital anomalies (Category 7) which made up 18 (38%) of the reviewed cases. This is an increase on the previous 2 years where 32% of cases in 2018-19 and 30% of cases in 2017-18 closed under this category
The second highest category was (Category 8) of Perinatal/Neonatal. These accounted for 30% of the total reviews. This is same as last year 2018-19 and slightly less than 2017-18 (32%), although higher than the 2016-17 figure of 26%. There were 8 (17%) deaths which were related to extreme prematurity.
Table 2: Categories with highest percentage of deaths analysed by panel in 2019-20
Category of closed case Percentage of Local Cases Percentage of National Cases (2019-20)
Chromosomal, genetic and 38% (n=18) 25% congenital anomalies (Category 7) Perinatal/Neonatal Event 30% (n=16) 31% (Category 8)
The relatively high percentage of category 7 deaths is notable compared to Nationally.
Modifiable Factors A modifiable factor is one from across any domain which may have contributed to the death of the child and which might, by means of a locally or nationally achievable intervention, be modified to reduce the risk of future child deaths In 2019-20 modifiable factors were identified in 14/47 (29%) of cases, which is lower than the previous 2 years where 39% of cases 2018-19 and 39% in 2017-18 had modifiable factors identified. This is lower than the national picture of 31%.
We have analysed the category of death including the percentage with a modifiable factor in each category. Note that due to small numbers, raw data has not been provided for each category; therefore percentages also need interpreting with caution. No reviewed cases were from category one in this year.
Page 15 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician
Figure 2: The proportion of child death reviews completed by Child Death Overview Panel with modifiable factors identified by primary category of death
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Deliberately inflicyed injury, abuse or neglect (Cat 1) 0%
Suicide or deliberate self-inflicted harm (Cat 2) 100%
Trauma and other external factors (Cat 3) 100%
Malignancy (Cat 4) 0%
Acute medical or surgical condition (Cat 5) 40%
Chronic medical condition (Cat 6) 100%
Chromosomal, genetic and congential anomalies (Cat 7) 22%
Perinatal/neonatal event (Cat 8) 31%
Infection (Cat 9) 0%
Sudden unexpected, unexpected death (Cat 10) 0%
Modifiable factors identified this year included maternal BMI, factors relating to Service Provision, Consanguinity and Physical Environment.
This year issues with Service Provision were identified as a modifiable factor in 9 (19%) of all cases reviewed. This is the same proportion as for 2018-19 (19%). Learning from serious incident reports, serious cases reviews and independent reviews is discussed in depth at CDOP panels and shared with relevant agencies and professionals as well as with the families of the children that have died.
Maternal BMI was noted as a modifiable factor in 4/47 cases reviewed Consanguinity, where parents are blood relatives, is a major risk factor for congenital anomaly. There were 4 (8.5%) cases where consanguinity was noted as a modifiable factor. The Panel continued to be concerned that families should have sufficient understanding of the increased risks of having a child with a disability or of having a child die under the age of five related to consanguinity. Although consanguinity featured less often in cases as a modifiable factor this year, it remains a priority within Luton and Bedfordshire to ensure that related parents are offered access to genetic counselling.
Page 16 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician
Figure 3: Modifiable factors identified most often in 2019-20
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0% Service Provision BMI Consanguinity
(Percentages of total cases reviewed in 2019-20)
Age, Gender and Ethnicity In Bedfordshire and Luton the number of deaths of children under 1 year of age reviewed during 2019-20 was 35 (74%); compared to 67 % in 2018-19 and 65% in 2017-18,
Perinatal deaths accounted for 18/47 (38%) compared to 41% nationally reviewed cases.
Deaths between 28 and 364 days accounted for 8/47 (17%) deaths compared to 22% nationally reviewed cases.
Deaths between 1 to 5 years of age accounted for 2/47 deaths.
Deaths between 5 to 10 years of age accounted for 2/47 deaths.
Deaths from 10 years old and above accounted for 10/47
Of the deaths reviewed at panel this year 51% were male and 49% were female, which is similar to last year whereby 52% were male and 48% female. This is a similar to the national data which shows that boys’ deaths account for half of the deaths reviewed (56%). National data has also shown that CDOP panels identified equal modifiable factors in reviews of boys’ deaths (32%) and girls’ deaths (32%).
In Bedfordshire there has been a variable distribution of percentage modifiable factor by gender due to the small number of cases analysed.
Page 17 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician
Figure 4: Gender of cases reviewed 2019-20 Gender
51%
49%
Male Female
Ethnicity of child deaths reviewed The ethnicity of children that died is summarised in Figure 5 below.23% of child deaths were of children of white ethnicity. Whilst in the year 2018-19 the percentage of deaths reviewed from Asian backgrounds was 19%, this year has greatly increased (40%) whereas the national trend is much lower at 16%. Of note, Asian ethnicity accounts for 5-10 % of children nationally in the under 18 age group (last census figure 2011. Ethnicity wasn’t always recorded (25% unknown).
Figure 5: Ethnicity of cases reviewed 2019-20
Page 18 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician
Ethnicity
27% 23%
White Asian 6% Black/ Africian/ Caribbean
2% Mixed 40% Not Known
4. Learning from Reviews and Actions Taken Service provision Factors related to Service Provision were identified by Serious Incident Investigations and Child Safeguarding Practice Reviews. These reports were reviewed by panel and alongside the related Action plans to ensure CDR partners were fully informed of the learning. The Panel reviewed 4 Serious Incidents cases during 2019-20.
Maternal BMI A BMI of 30 or more at the booking appointment poses a risk, both to a mother’s health and the health of the unborn child. High BMI has been noted in child death reviews locally. CDOP has shared the emerging themes from the Child Death Reviews with Public Health to inform local policy relating to maternal obesity.
NICE guidance is available for professionals supporting women before, during and after pregnancy and should inform access to advice regarding healthy eating and lifestyle and advice to lose weight after the pregnancy if the woman is not in a healthy range. https://www.nice.org.uk/guidance/ph27
Page 19 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician
Consanguinity Genetic counselling is available to families locally and where consanguinity has been identified; panel seeks assurance that families have had the opportunity to receive genetic counselling.
Environment This year there were a very small number of cases identified where the environment was felt to be modifiable. Environmental factors included in previous year’s related road and water safety.
CDOP Training Sessions CDOP training continues to be part of the Level 3 Safeguarding Training for GPs within Bedfordshire and Luton. This has continued to work effectively and has received positive feedback. Training has been carried out by MS Teams due to the pandemic which can continue in the coming year. Training includes understanding why children die, sharing themes from local deaths and informs agency partners in their role in contributing to collecting information around child deaths and supporting families.
Performance The Panel will hold more frequent Neonatal Themed Panels in order to improve the timeliness of reviews. More general CDOP have been planned in the coming year to increase the number of cases to review and analyse learning.
Analysis CDOP will record ward of residence going forward to see if there are emerging themes in relation to index of deprivation. The designated doctors contribute to the Eastern region CDOP and will be sharing modifiable factors identified at our panel to ensure that there is consistency across the region.
Our action plan for the coming year will focus on the following through partnership working with all agencies:-
Maternal healthy weight Service modifiable factors Consanguinity To link in with other work streams including Local Maternity Services to share the wider learning particularly from perinatal deaths where service modifiable factors have been identified.
Page 20 of 20 CDOP Annual Report 2019/2020 Written by: Dr Catherine Kearney - Designated Paediatrician and Sandra Watts – CDOP Manager Contributions from: Helena Hughes – Designated Nurse for Safeguarding Children & Young People and Dr Amjad Khan – Designated Paediatrician