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1
Child Death Overview Panel
Annual Report 2013-2014
Document Name & File Location
K:\FSC KSCB\CDOP\Annual Reports\Reports\2014
Document Author Sue Gower
Document Owner©
Kent Safeguarding Children Board ©
Sessions HouseCounty Road, Maidstone. Kent. ME14 1XQ
Email: [email protected]
Summary of Purpose
The requirement for LSCBs to review all child deaths became a statutory requirement from 1st April 2008. The process is outlined in Working Together to Safeguard Children 2013. In Kent this review process has been the Child Death Overview Panel (CDOP). This document provides an analysis of the deaths that occurred April 2013 - March 2014.
Accessibility This document can be made available in large print, or in electronic format.
There are no copies currently available in other languages
How this document was created
Draft 1 Document created by SG
Draft 2 Review by Chair
Draft 3 Ratification by CDOP Panel
Draft 4 Sign off by Business Group and Board
Equalities Impact Assessment
During the preparation of this policy and when considering the roles & responsibilities of all agencies, organisations and staff involved, care has been taken to promote fairness, equality and diversity in the services delivered regardless of disability, ethnic origin, race, gender, age, religious belief or sexual orientation. These issues have been addressed in the policy by the application of an impact assessment checklist.
Circulation Restrictions
Version Detail of change Date
1.0 Andrew Scott-Clark July 2014
2.0 Sue Gower July 14
3.0
2
Contents
Number Section Page
1. Foreword 4
2. Introduction 5
3. Scope of Reviews and Common Terminology 6
4. The process following the death of a child 7
5. Child Death Review Process 8
6. Statistics – Reported Cases 9
7. Statistics – Reviews carried out by CDOP 11
8. Time Taken to Complete Reviews 12
9. Modifiable Factors 13
10. Serious Case Reviews 14
11. Achievements 15
12. Learning Points 15
13. Training 15
Appendix A – Definition of Child Death Terms 16
Appendix B – Definitions of categories as required by the Department for Education and used by CDOP
17
Appendix C – Membership of the CDOP18
3
1. Foreword
This year has seen a number of changes in personnel within the core CDOP team.
Having served as Chair of the Kent CDOP Panel for a number of years, Meradin
Peachey left in March 2014 to take up the position of Tri-Borough Director of Public
Health for Hammersmith and Fulham, Kensington and Chelsea and Westminster. I
assumed this responsibility in my role as Interim Director of Public Health in March
2014. Sue Gower, KSCB Programme Development Officer came into post in
August 2013 and is now the KSCB officer with responsibility for CDOP replacing
Lesley Burnand. Sue Gibbons was appointed by KCHT as Specialist Nurse, Child
Death, taking over the role formerly held by Dawn Bissett.
Improvements to local CDOP processes continue to take place and in order to
expedite cases, specific meetings are now held to consider neonatal and SUDI
(Sudden Unexpectedly Death in Infancy) cases respectively. In this way, the Panel
is able to review and ‘sign’ these off these cases as quickly as possible. As a result
of work detailed in last year’s Annual Report, communications between local
settings and specialist hospitals in London who share the care of children in Kent
have improved and the safe sleeping campaign that commenced at the end of the
2012-13 reporting period has been reviewed and revised.
Any child death is a tragedy, and I am grateful to members of the CDOP panel for
their commitment to this process and the respect that is shown for the children,
young people and families concerned at each meeting.
Andrew Scott-ClarkChair of the Child Death Overview Panel
4
2. Introduction
This is the fifth annual report of the Child Death Overview Panel (CDOP) in Kent.
The Panel was established on 1st April 2008 in line with Government guidance
outlined in ‘Working Together to Safeguard Children’ (HM Government 2006 and
updated in 2010 and 2013). The guidance states that all child deaths (excluding
stillbirths and planned terminations of pregnancy carried out within the law) up to
the age of 18 should be monitored and places the expectation on Local
Safeguarding Children Boards (LSCB) that they will:
Collect and analyse information about each death;
Put in place procedures for ensuring that there is a co-ordinated response to
an unexpected death.
The process of responding to a child death is set out in Chapter 5 of HM
Government’s statutory guidance: ‘Working Together to Safeguard Children’ March
2013. It sets out both the method in which a child death should be investigated by
the agencies to establish how a child died and the subsequent review process. The
review is in addition to any investigation carried out on behalf of the coroner. The
Child Death Overview Panel will also examine those deaths where there has been
no coronial involvement.
The key purpose of reviewing all child deaths is to identify learning and any
modifiable factors that can be addressed by further consideration. These findings
are shared with the DfE who take a national overview of the issues. The detailed
guidance on how a child death should be investigated in Kent can be found in the
Unexpected Death of a Child Procedures (May 2013). The detailed procedure for
reviewing the death of a child is set out in the Child Death Overview Procedures
and Practice Guidance (May 2013). Both of these policies can be found at
www.kscb.org.uk. They can also be found online in the Kent and Medway
Safeguarding Children Procedures: 2.5.3 Child Death Reviews.
5
3. Scope of reviews and Common Terminology
The Child Death Overview Panel has the responsibility to review the death of all
children who are resident within KSCB's geographical area from birth up to the age
of 18 years.
Common Terms relating to Infant Death
6
4. The Process following the death of a child
Definition of Unexpected Death
The death of an infant or child (less than 18 years) which:
Was not anticipated as a significant possibility 24 hours before the death; or
Where there was a similarly unexpected collapse or incident leading to or precipitating the events which led to the death.
7
5. Child Death Review Process
All child deaths must be reported to KSCB by the relevant agency within 24 hours.
Agencies who knew the child are then formally asked to provide any known
information about the child, their family, their environment and services provided.
This information is collated between 4 and 8 weeks after the death, following which
it is then reviewed by the Child Death Overview Panel (CDOP) which meets
monthly. The CDOP is made up of representatives from health (paediatricians
and nurses), police, education, children’s social services, Foundation for Study of
Infant Deaths, ambulance service and the KSCB, (Appendix B details members).
Other specialists are invited to attend specific meetings when their expertise is
required e.g. neonatologist, Police Serious Crash Investigator.
The CDOP are required to categorise every death using the framework below, and
to identify any modifiable factors i.e. actions that could be altered. These are
discussed and recommendations made in order to raise awareness of any issues
and to prevent future deaths. Gaps in service provision both prior to the death and
afterwards, such as bereavement support are also identified and any public health
issues considered.
Deliberately inflicted injury, abuse or neglect
Suicide or deliberate self-inflicted harm
Trauma and other external factors
Malignancy
Acute medical or surgical condition
Chronic medical condition
Chromosomal, genetic and congenital anomalies
Perinatal/neonatal event
Infection
Sudden unexpected, unexplained death
8
6. Statistics - Reported Cases
The following statistics have been compiled from data received by KSCB from
partner agencies throughout the year in question.
a. Number of Deaths for 2013/2014, highlighting Unexpected Deaths
Although the number of deaths was consistent in the reporting years 2009-10,
2010-11 and 2011-12, there has been a decrease in numbers in the current
reporting period. The numbers of unexpected deaths rose during the 5 reporting
periods in question but have decreased in 2013-14. The numbers of deaths are
shown below:
Number of deaths
Number of unexpected
deaths2009/10 94 352010/11 94 412011/12 94 402012/13 99 522013/14 63 34
b. Number of Deaths by Age
9
The largest number of deaths by age consistently falls within the neonatal group,
with the lowest number of deaths between the ages of 5 and 9. The breakdown of
data by age is shown below:
2009/10 2010/11 2011/12 2012/13 2013/140-28 days 31 39 42 48 2529-365 days 25 27 12 20 161-4 years 11 6 12 8 95-9 years 7 9 5 7 510-14 years 7 6 11 <5 515-18 years 13 5 12 11 3unknown 0 0 0 0 0
10
c. Number of deaths by gender
Kent data consistently identifies more deaths of male children than female, detailed below:
2009/10 2010/11 2011/12 2012/2013 2013/14Female 43 41 40 42 28Male 51 51 52 56 35
7. Statistics – Reviews carried out by CDOP 2013/14
During 2013/14 the CDOP met 10 times and completed the reviews of a total of 91
cases.
The difference between this data and the total number of deaths notified within the
year is often due to an inherent backlog in the gathering of information and waiting
for the completion of Post Mortems, Inquests or Criminal Proceedings. Over the
three year period the number of deaths which had taken 6 months or longer to
review and complete peaked during 2009/10 and is gradually being reduced from
this point.
11
The data in the above chart relates to deaths where the review has been completed
by the CDOP each year. The panel have reviewed 310 deaths in four years.
8. Time taken to complete reviews 2013-14
The data in the above chart relates to the time taken between the date of death and
when the review has been carried out. The target is for the review to take place
12
between 3 and 6 months. The timescales of data collection and time taken to
review cases has been improving significantly over the past year. Most delays of
more than 6 months relate to waiting for inquests to be completed or criminal
proceedings. There are also delays in reviewing some cases, as Kent groups the
types of deaths into themed meetings and invite experts in particular areas in order
to assist with these reviews. However the streamlining of Kent’s procedures will
continue to see improvements in the time taken to review cases.
The Child Death Overview Panel will take into consideration every known factor
relating to the child, the family, home circumstances, parenting capacity and
service provision—in particular to identify where there are gaps. The Panel is then
required to categorize the primary cause of the death. The definition for each
category is shown in Appendix B.
Category of Death
2011/12 2012/13 2013/14Deliberately inflicted injury, abuse or neglect 0 <5
<5
Suicide or deliberate self-inflicted harm <5 <5 <5Trauma and other external factors 5 5 7Malignancy 9 12 6Acute medical or surgical condition 0 5 <5Chronic medical condition <5 14 <5Chromosomal, genetic and congenital anomalies 7 5
11
Perinatal/neonatal event 20 25 22Infection <5 <5 <5Sudden unexpected, unexplained death <5 12 13
9. Modifiable Factors Identified 2013-14
The CDOP consider whether there are any modifiable factors which, if addressed,
may prevent similar deaths in the future. It also seeks to identify:
any lessons to be learned from the death,
patterns/similar deaths in the area.
13
Of the 91 cases reviewed there were 15 (18% of total reviewed deaths) which were
identified as having modifiable factors. These factors include:
• Supervision in the bath
• Smoking x 3
• Inappropriate sleeping arrangements for infants
• Appropriate parental access to medical help
• Road safety and safety markings
• Cycle helmets and lights
• Inexperienced drivers/seat belts/road safety
• Co-sleeping x 3
• Room temperature x 3
• Alcohol/Substance misuse
• Transfer of new born infant
• Delay in Caesarean procedure.
10. Serious Case Reviews (SCRs)
Local Safeguarding Children Boards (LSCB’s) are required to undertake Serious
Case Reviews when a child dies and neglect or abuse is known or suspected. The
requirements for Serious Case Reviews are set out in Chapter 7 of ‘Working
Together to Safeguard Children’ 2013.
The KSCB Serious Case Review Panel determine whether a Serious Case Review
should be commissioned, either as part of the statutory requirement or where it is
felt that the resulting information will inform practice. No new SCRs were
commissioned in 2013/14.
Copies of all Executive Summaries arising from Serious Case Reviews and
management reviews undertaken by the Kent Safeguarding Children Board are
published on the Board’s website: www.kscb.org.uk
14
11. Achievements
The CDOP has considered more cases this year and has improved the quality of
information and learning points that result from the meetings.
12. Learning Points
The following learning points have been identified during the period of this report:
Education of parents to provide supervision of child at bath time – a ‘safe
bathing’ message.
The need for timely transfer of neurosurgical children.
Reduction in smoking in pregnancy.
The impact of an adult’s condition (alcohol or substance misuse or mental
health issues) can have on children and young people in the family.
The use of bedding rather than duvets in a cot and an understanding of the
correct room temperature for a baby
The need to continue with ‘stop smoking’ activity before, during and after
pregnancy.
The need to reduce co-sleeping
13. Training
During 2013-14, a total of 50 practitioners attended four training sessions relating to
the Child Death Review Process. In addition, joint training is now carried out in
partnership with Kent Police as part of SCAIDP.
15
APPENDIX A
Child Death Terms
Neonatal: The death of an infant from any time after birth until the age of 28 days.
Infant death: The death of any infant up to a year.
Pre-viable neonatal death: For the purpose of CDOP review, a pre-viable neonatal death is any infant who was born below 24 weeks gestation with signs of life.
Sudden Unexpected Death in Infancy (SUDI): (Descriptive term) The sudden unexpected death of an infant under one year of age.
Sudden Infant Death Syndrome (SIDS)(Willinger et al 1991) The cause of death of an infant <1 year cannot be explained despite a full history, multi-agency investigation physical examination, and paediatric post mortem findings performed to a standardised protocol.
Unexpected deaths: The death of an infant or child (less than 18 years old) which: was not anticipated as a significant possibility, for example, 24 hours before
the death; or where there was a similarly unexpected collapse or incident leading to or
precipitating the events which led to the death.
Expected deaths: All other deaths, for example those due to lethal genetic abnormalities, cancer, neurodegenerative conditions, etc. It should be noted that some children with these conditions may die unexpectedly and such deaths may need to be assessed sensitively by the Rapid Response Team. For information on the Rapid Response process, see KSCB Procedures at www.kscb.org.uk
Modifiable factors: One or more factors, which may have contributed to the death of the child and which, by means of locally or nationally achievable interventions, could be modified to reduce the risk of future child deaths.
16
APPENDIX B
Department for Education CDOP Categories
1. Deliberately inflicted injury, abuse or neglectThis includes suffocation, shaking injury, knifing, shooting, poisoning & other means of probable or definite homicide; also deaths from war, terrorism or other mass violence; includes severe neglect leading to death.
2. Suicide or deliberate self-inflicted harmThis includes hanging, shooting, self-poisoning with paracetamol, death by self-asphyxia, from solvent inhalation, alcohol or drug abuse, or other form of self-harm. It will usually apply to adolescents rather than younger children.
3. Trauma and other external factorsThis includes isolated head injury, other or multiple trauma, burn injury, drowning, unintentional self-poisoning in pre-school children, anaphylaxis & other extrinsic factors. Excludes Deliberately inflected injury, abuse or neglect. (category 1).
4. MalignancySolid tumours, leukaemias & lymphomas, and malignant proliferative conditions such as histiocytosis, even if the final event leading to death was infection, haemorrhage etc.
5. Acute medical or surgical conditionFor example, Kawasaki disease, acute nephritis, intestinal volvulus, diabetic ketoacidosis, acute asthma, intussusception, appendicitis; sudden unexpected deaths with epilepsy.
6. Chronic medical conditionFor example, Crohn’s disease, liver disease, immune deficiencies, even if the final event leading to death was infection, haemorrhage etc. Includes cerebral palsy with clear post-perinatal cause.
7. Chromosomal, genetic and congenital anomaliesTrisomies, other chromosomal disorders, single gene defects, neurodegenerative disease, cystic fibrosis, and other congenital anomalies including cardiac.
8. Perinatal/neonatal eventDeath ultimately related to perinatal events, egsequelae of prematurity, antepartum and intrapartum anoxia, bronchopulmonary dysplasia, post-haemorrhagic hydrocephalus, irrespective of age at death. It includes cerebral palsy without evidence of cause, and includes congenital or early-onset bacterial infection (onset in the first postnatal week).
9. InfectionAny primary infection (i.e., not a complication of one of the above categories), arising after the first postnatal week, or after discharge of a preterm baby. This would include septicaemia, pneumonia, meningitis, HIV infection etc.
10. Sudden unexpected, unexplained deathWhere the pathological diagnosis is either ‘SIDS’ or ‘unascertained’, at any age. Excludes Sudden Unexpected Death in Epilepsy (category 5).
17
APPENDIX CMembership of CDOP
Name Agency Title
Meradin PeacheyAndrewScott-Clark
Kent Public Health Department
Kent Director of Public Health/ Chair of CDOP
Interim Director of Public Health/Chair of CDOP
Charles Unter Maidstone & Tunbridge Wells NHS Trust
Vice Chair/ Consultant Paediatrician
Kel Arthur CFE/ Education Services Children’s Education Safeguarding Manager
Lesley BurnandSue Gower
Kent Safeguarding Children Board
KSCB Training Development Officer
KSCB Partnership Development Officer
Andy Pritchard Kent Police Detective Chief Inspector
Dawn Bissett/Sue Gibbons
Kent Community Health NHS Trust
Specialist Nurse Child Death
Selwyn D’Costa Dartford & Gravesham NHS Trust
Consultant Paediatrician & Named Doctor
Colin Green East Kent Hospital University Foundation NHS Trust
Consultant Paediatrician & Designated Doctor for Ashford, Folkestone &Shepway
El Hussein Rfidah East Kent Hospital University Foundation NHS Trust
Consultant Paediatrician & Designated Doctor for Child Death Review for Thanet & Dover
Amitha Sumathipala East Kent Hospital University Foundation NHS Trust
Consultant Paediatrician & Designated Doctor for Child Death Review for Canterbury & Coastal Areas & Swale
Judith Howard Lullaby Trust Regional Development Officer
Jane Mitchell South East Coast Ambulance Service
Safeguarding Children & Adults Manager
Paul Brightwell Performance and Quality Assurance Manager (Children in Care)
KCC – FSC
Trish Stewart Named Nurse for Safeguarding Children Assurance Lead
KCHT
18