child death overview panel...

CHILD DEATH OVERVIEW

PANEL (CDOP)

ANNUAL REPORT 2014 – 2015

2014 – 2015 MKSCB CDOP annual report

2

Contents

1. Introduction 3

1.1 Function of Local Safeguarding Board in Child Deaths

2. Membership and Panel Meetings 4

3. Child Deaths Statistics 5

3.1 National Comparative Data

3.2 Local Data

3.3 Expected and unexpected child deaths

3.4 Place of death

3.5 Gender

3.6 Ethnicity

4. CDOP Process and overview of findings 9

4.1 Inquests held

4.2 Causes of child deaths

4.3 Categories of child deaths

5. Modifiable factors and learning from child deaths 11

5.1 Review of sudden unexpected deaths in childhood 2010- 2014

5.2 Modifiable factors and learning from child deaths 2014/15

6. Recommendations for CDOP in 2015/16 13


3

1 INTRODUCTION In 2013, the infant mortality rate was 3.8 deaths per 1,000 live births, the lowest ever recorded in

England and Wales. This compares with an infant mortality rate of 4.0 deaths per 1,000 live births in

2012 and 10.1 deaths per 1,000 live births in 19831.

Despite the downward trend, evidence in the Marmot Review: Fair Society, Healthy Lives2 noted

that factors, including births outside marriage, maternal age under the age of 20 and deprivation,

were independently associated with an increased risk of infant mortality. The review went on to say

that ‘low birthweight in particular is associated with poorer long-term health outcomes and the

evidence also suggests that maternal health is related to socio-economic status’.

Milton Keynes Safeguarding Children Board (MKSCB) has a statutory responsibility to review child

deaths. From 1 April 2008, all deaths of children up to the age of 18 years (excluding stillbirths and

planned terminations) have been reviewed by a panel of people from a range of organisations and

professional areas of expertise. This review is produced by the Child Death Overview Panel (CDOP)

in accordance with the national guidance, ‘Working Together to Safeguard Children 2015’.

This is the seventh Child Death Overview Panel (CDOP) annual report to the MKSCB. It will

provide an overview of the child deaths that were reviewed during the period 1 April 2014 – 31

March 2015. This includes deaths prior to April 2014, reflecting the time taken to gather sufficient

information from relevant agencies or service providers.

This report provides some analysis of deaths within the year 2014/15, but most analysis refers to

cases actually reviewed within the year. The number of deaths recorded in 2014/15 is 27 and the

number of cases reviewed, relating mainly to previous years, is 28. Most data is reported in year

periods from 1st April to 31st March the following year.

1.1 Function of Local Safeguarding Board in Child Deaths

The Local Safeguarding Children Board (LSCB) functions in relation to child deaths are set out in

Regulation 6 of the Local Safeguarding Children Boards Regulations 2006, made under section

14(2) of the Children Act 2004. The LSCB is responsible for:

a) Collecting and analysing information about each death with a view to identifying:

(i) Any case giving rise to the need for a review mentioned in regulation 5(1)(e);

(ii) Any matters of concern affecting the safety and welfare of children in the area of the

authority;

(iii) Any wider public health or safety concerns arising from a particular death or from a

pattern of deaths in that area; and

b) Putting in place procedures for ensuring that there is a coordinated response by the

1

ONS (2015) Childhood, Infant and Perinatal Mortality in England and Wales,2013 2

Marmot M (2010) Fair Society, Healthy Lives: A Strategic Review of Inequalities in England. London: University College London


4

authority, their Board partners and other relevant persons to an unexpected death.

This panel review process is undertaken for all children who are normally resident in Milton Keynes.

The purpose is not to allocate blame but to identify learning and put actions in place to reduce the

risk of future deaths. We aim to:

Identify actions we can take that might help to prevent similar deaths in the future.

Identify possible trends and target relevant interventions

Share learning with colleagues regionally and nationally so that any themes can be identified

for regional or national action.

2 MEMBERSHIP AND PANEL MEETINGS Key strategic leads from within Milton Keynes organisations are represented at the CDOP meeting,

together with the CDOP administrator and the designated doctor for child deaths.

As at 31 March 2015, the CDOP panel members were as follows:

Member Organisation

Elaine Coleridge Smith MKSCB Independent Chair & Child Death Overview Panel chair

Dr Keya Ali Designated Doctor Child Death, Milton Keynes Clinical Commissioning

Group

Sonia Brooks Coroners Officer Supervisor, Milton Keynes Council

Melinda May Head of Delivery, Children’s Social Work, Milton Keynes Council

Dr Ivo Haest Public Health Consultant

Phil Hayes Detective Inspector, Thames Valley Police

Sandy Webster Lead Professional for Safeguarding Children, Milton Keynes Hospital NHS

Foundation Trust

Tracy Rea Bereavement Midwife, Milton Keynes Hospital NHS Foundation Trust

The MKSCB CDOP met four times and reviewed 28 deaths between 1 April 2014 and 31 March

2015. Many of those reviewed occurred in previous years, the earliest being from December 2011.

This is due to the time required to bring together relevant information from different agencies.


5

3 CHILD DEATH STATISTICS

3.1 National Comparative Data

Official data from the Office for National Statistics (ONS) is included below. This data enables us to

compare MK rates with national rates.

Figures 1 and 2 below show national comparisons between the rate of deaths per 1,000 births

under 28 days of age and under one year. We cannot fully interpret comparative rates, especially

when assessing small numbers. The dotted pink line indicates a range of values within which we

can be 95% confident that the true value lies.

For most years the confidence interval crosses the national rate so we cannot be sure that the rate

of deaths in MK is different than the rate in England. However, there is a statistically significant

difference between the rate in 2013 (Figure 1) and in both 2003 and 2013 (Figure 2). Figure 3

shows the number of child deaths and child mortality rates per 100,000 for deaths between one and

17 years of age. There is no statistically significant difference between Milton Keynes and England.

Figure 1: Neonatal deaths under 28 days (per 1,000)

Figure 2: Infant deaths under 1 year


6

Figure 3: Deaths between 1 and 17 years (three years pooled data)

3.2 Local data

In 2014/15, 25 children died who resided within the LSCB area and two children died who resided

outside MKLSCB area, in Northampton and Luton.

As can be seen from Table 1, the total number of child deaths in any year fluctuates. The

confidence intervals described above have indicated whether this represented a statistically

significant difference compared to national figures. The 2014/15 figure is just below the average for

the seven year period.

Table 1: Total number of child deaths

2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15

36 33 28 18 24 40 27

A child is most at risk of death within the first year of life, and particularly within the first 27 days of

life3. Between 1 April 2010 and 31 March 2015, 47% of deaths reviewed in Milton Keynes were

neonatal deaths (<28 days old) and 17% were between 28 days and one year of age.

Table 2 shows a comparison between five years aggregated data (Apr2010-March2015) compared

to current year (2014/15). The table shows that, as expected, the highest risk of death is in the

period under 28 days of life, followed by the next period up to one year. The proportion of infant

deaths amongst all those reviewed is consistent with the national figure of 64%.

3 RCPCH 2014 Why Children Die http://www.rcpch.ac.uk/news/rcpch-and-ncb-launches-report-why-children-die


7

Table 2: Five year aggregated data (Apr2010-March2015) of reviewed cases and current year

(2014/15); number of child deaths by age

0 – 27

days

28 – 364

days

1 – 4

years

5 - 9

years

10 – 14

years

15 – 17

years

Totals

2010/11-

2014/15

5 years

63

(47%)

22

(17%)

24

(18%)

12

(9%)

6

(5%)

6

(5%)

133

(101%)

2014/15

11

(39%)

7

(25%)

7

(25%)

1

(4%)

2

(7%)

0

28

(100%)

Note: percentages may not add up to 100% due to rounding

3.3 Expected and unexpected child deaths

Child deaths are classified as either expected or unexpected. An unexpected death is defined as

‘the death of an infant or child (less than 18 years old) which (excluding stillbirths) was not

anticipated as a significant possibility, for example, 24 hours before the death, or where there was

an unexpected collapse or incident leading to or precipitating the events which lead to the death’4. It

is the responsibility of the attending doctor and the police to ascertain if the death is unexpected.

Local data shows that the proportion of deaths defined as unexpected in the last five years

(Apr2010-March 2015) is 31% and for 2014/15 is 29% (8).

3.4 Place of death

Of the 28 deaths reviewed in 2014/2015, 25 occurred in hospital, two occurred in a hospice and one

death occurred in a road traffic incident in MK.

3.5 Gender

Over the years boys’ deaths have consistently accounted for over half of deaths reviewed5. Table 3

below shows MK is consistent with this with 57% of deaths occurring in males compared to 43%

occurring in females during the five year period.

Table 3: Comparison of child deaths occurring in males and females 2010-2015

Male Female Totals

2010/11- 2014/15

5 years

77

(57%)

57

(43%)

135 (1 indeterminate excluded)

2014/15

18 (64%)

10 (36%)

28

4 HM Government 2015 Working together to safeguard children

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/419595/Working_Together_to_Safeguard_Children.pdf 5 Department for Education 2015 Child Death Reviews – Year ending March 2015


8

3.6 Ethnicity

In 2014/15, all deaths reviewed by MKSCB CDOP had identified ethnicities. It is not

possible to identify any over-represented ethnic groups from the small numbers involved

and the data appears to reflect the population make-up of MK.

Table 5: Ethnicity of the 28 child deaths reviewed in 2014 – 2015

Ethnicity number

White: English/Welsh/Scottish/Northern Irish/British 15

White: Any Other White background 1

Mixed/Multiple ethnic groups: White and Black Caribbean 1

Mixed/Multiple ethnic groups: White and Black African 1

Asian or Asian British: Pakistani 4

Asian or Asian British: Bangladeshi 2

Asian or Asian British: Any other Asian background 2

Black/Black British: Caribbean 1

Black/Black British: African 1

Totals 28


9

4 CDOP PROCESS AND OVERVIEW OF FINDINGS

The CDOP panel is made up of relevant strategic leads from across Milton Keynes organisations,

the CDOP administrator and the designated doctor for child deaths (see above). A child’s death will

be reviewed by the CDOP using as much information from relevant agencies, including information

gathered from any rapid response case reviews, strategy meetings, MASH discussions, Agency

Report Forms (Form B) and Coroner’s inquests. Reviews are delayed until all relevant information

has been received from the relevant agencies.

When an unexpected child death occurs there are specific actions that must be taken by

professionals. Within this process the police as the lead agency or the Consultant Paediatrician will

ensure that a ‘rapid response’ case review discussion takes place within 48 hours of the child’s

death. There were eight unexpected child deaths during the period of this report.

Where the child death is expected, the notification is received by CDOP and each agency that knew

the child prior to their death completes an ‘Agency Report Form’, known locally and nationally as

Form B. This form captures all the relevant information about the child and family to inform CDOP

consideration of modifiable factors.

During 2014–2015 the local rapid response processes and procedures were reviewed and revised

and all child deaths are now reported to the Multi-Agency Safeguarding Hub (MASH). Where the

death is unexpected, a record of the multi-agency case review discussions are forwarded to the

CDOP coordinator.

Of the 28 cases reviewed in 2014/15, 50% of the deaths occurred more than one year prior to the

review date. The percentage of these late reviews over the five year period ranges from 10% to

54% and there is no identifiable trend. There are 21 child deaths which occurred in 2014/2015 that

have not yet been taken to panel.

4.1 Inquests held

It is the Coroner’s responsibility to determine the cause of death where this is not known. Out of the

eight unexpected child deaths in 2014/2015, six (75%) were scheduled to be heard by a Coroner at

an inquest. Out of those six child deaths, four (67%) have been heard by a Coroner and a further

two (33%) are to be heard by a Coroner later in 2015.

4.2 Causes of child deaths

The ONS Childhood, Infant and Perinatal Mortality in England and Wales report6 identified

immaturity-related conditions (e.g. respiratory and cardiovascular disorders) as the most common

cause of infant deaths in 2013, with 44% due to these causes. Immaturity-related conditions

accounted for 14% of all post-neonatal deaths and 57% of all neonatal deaths. Congenital

anomalies were another major cause, accounting for 28% of all infant deaths. Congenital anomalies

accounted for 32% of all post-neonatal deaths and 27% of all neonatal deaths.

6

ONS 2015 Childhood, Infant and Perinatal Mortality in England and Wales 2013 http://www.ons.gov.uk/ons/dcp171778_397789.pdf

http://www.ons.gov.uk/ons/dcp171778_397789.pdf


10

The child death reviews completed by CDOP during the period 2010-2015, identified the causes of

death as detailed in Table 6.

Table 6: Causes of Child Deaths 2010- 2015

2014/15

2013/14

2012/13 2011/12 2010/11 Total

Neonatal death 10

11

13

13 14

61

Known life-limiting

condition

8

4

6

6

10

34

Sudden unexpected

death in infancy

3 1 1

3

8

Road traffic

accident/collision

0

Drowning

0*

Fire and burns 1

1

Poisoning

Other non-intentional

injury/ accident/ trauma

1

1

2

Substance misuse

Apparent homicide 1

1

Apparent suicide 3

3

Other 7

3

2

6

6

24

Total 134

* One Milton Keynes child death was caused by drowning, outside our area and was reviewed by another CDOP.

The MKSCB CDOP has reviewed a total of 134 Milton Keynes children over the five year period to

April 2015. Neonatal deaths accounted for 46% (61) of these recorded deaths and 25% (34) of the

deaths were recorded as ‘known life-limiting condition’.

In 2014/15, 35.7% of the deaths reviewed by MKSCB CDOP were caused by events in the neonatal

period. This is comparable with one third nationally.

4.3 Category of child deaths

During the CDOP meeting the panel members are required to categorise each child’s death and this

is recorded on the CDOP system. The category headings are national headings which are

determined by the Department for Education (DfE).

The table below gives a breakdown of the numbers of child deaths recorded under each of the

nationally identified categories. The list of categories is hierarchical, that is if the CDOP considers


11

there are two possible categories to record for the child death, the category that is the highest on

the list should be recorded on the CDOP Form C. Form C is the Analysis Proforma that is used by

the CDOP when evaluating the information for each child death, identifying lessons to be learnt, and

making any recommendations. The collated information from the Form C is also submitted to the

DfE for the annual data submission.

Table 7: Categories of Child Deaths for the 5 year period 2010-15 and 2014-15

Category 2014/15 April2010-March2015

5 Year Period

Total

Deliberately inflicted

injury, abuse or neglect

0 2 2

Suicide or deliberate

self-inflicted harm

0 3 3

Trauma and other

external factors

0 2 2

Malignancy

3

7

7

Acute medical or

surgical condition

4

14

14

Chronic medical

condition

4

4

Chromosomal, genetic

& congenital anomalies

4

26 30

Perinatal/

neonatal event

10

53 53

Infection

4

13 13

Sudden unexpected,

unexplained death

3 9 9

As can be seen in the table above, the majority of child deaths over the last five years have been

categorised as ‘perinatal/neonatal events’ or ‘chromosomal, genetic & congenital anomalies’.

5 Modifiable factors and learning

5.1 Review of sudden unexpected deaths in childhood 2010- 2014 In 2014, there was a review of 20 sudden unexpected deaths in childhood over the period 1st April 2011 to 15th May 14, 15 of which related to the MKCDOP7. Nine of these cases were reviewed at a CDOP meeting and four were categorised as having modifiable factors (see below), three relating to sudden unexpected death in infancy (SUDI) and one relating to delayed medical diagnosis. There were no road accidents or domestic accidents and the contacts aspect of the infectious disease death was well handled.

7

Latham and Ali (2014) Review of sudden unexpected deaths in childhood 2010-2014 [email protected]

mailto:[email protected]


12

The learning identified from this review was around the management of heart murmurs and

headache and an escalation procedure in critical illness. New protocols and procedures were

written with help from parents. Also, whilst feedback from bereavement support was positive in non-

complex cases, where diagnosis was complex, a key learning point was identified around working

more closely with the Coronial System to keep parents better informed as to what is happening.

There was also learning around engaging with parents who were angry with the health system.

The key recommendations from this report are as follows:

1. Designated Doctor for Child Death and CDOP chair to meet with Coroner to discuss availability

of autopsy reports and introduction of pre-Inquest meeting as per WTSC.

2. Strengthen the coordination and administrative functions that support the Rapid Response

process to enable effective sourcing and collation of information from all involved agencies.

3. Review the procedures and systems and processes that support rapid response to identify if

there are any areas that could be strengthened.

Actions taken during 2014-15 are as follows:

1. It was agreed that a meeting between the Coroner, Designated Doctor for Child Death and

CDOP Chair was no longer required as the process had changed and was now more effective.

2. All unexpected child deaths are now reported to the MK MASH. This process was agreed and

started on13 October 2014.

3. Two workshops were held to map and strengthen the processes that support rapid response.

4. The revised rapid response chapter was approved by the MKSCB BMG on 24 June 2015 and

will be incorporated into the MKSCB web-based procedures at the next scheduled update in

autumn 2015.

5.2 Modifiable Factors and learning from child deaths 2014/15

Modifiable factors are defined as ‘those, where, if actions could be taken through national or local

interventions, the risk of future child deaths could be reduced.”8 Modifiable factors include smoking/

obesity in pregnancy, consanguinity (blood relation), drug/alcohol abuse, poor parenting, outdoor

safety (e.g. swimming/bike helmets), safe sleeping (sleeping position etc.), medical care and road

traffic incidents. The CDOP panel review provides the opportunity to identify any local, regional or

national modifiable factors that may have prevented the death of the child.

Nationally, in 2014/15, the percentage of child death reviews identified as having modifiable factors9

identified is 24%, a rise from 20% in 2011. In the five year period (2010-2015), 20% of cases in MK

were identified with modifiable factors and 21% (6) in 2014/15.

The modifiable factors identified from the review of all deaths in childhood for the 2014-2015 period

were consanguinity (2), safe sleeping (3), smoking (1).

8

Department for Education 2015 Child Death Reviews – Year ending March 2015 9 www.workingtogetheronline.co.uk/chapters/chapter_five.html


13

6. Recommendations for CDOP in 2015/16

Future reports

A new template for the production of this report is recommended, including a section to

report on actions taken against the recommendations of previous reports – a rolling action

log would be useful.

In view of the small numbers involved, all future reports could reflect a comparison between

a five year period and the current year

Premature births under 24 weeks gestation - it is clear from discussions with ONS analysts,

that not all hospitals are reporting deaths under 24 weeks gestations (where there are initial

signs of life). For those areas that do report these events as deaths, this may inflate the

death figures and they are therefore not directly comparable with the national or regional

statistics. For this reason, it is recommended that these deaths are treated separately and

an analysis of gestation is provided in the report.

Action on modifiable factors

Consanguinity - The CDOP panel could consider what actions can be taken to reduce deaths

related to consanguinity.

Smoking – In view of the clear negative impact of smoking in pregnancy, the CDOP panel could

seek to use its influence to strengthen the uptake of stop smoking support in pregnancy.

Safe Sleeping – the CDOP panel should continue to support the campaigns relating to safe

sleeping.

Other

The CDOP should introduce a quality measure for the timeframe within which cases are

reviewed, always accepting that a proportion will be delayed.

A specialist themed panel could be set up, with co-opted membership, for neonatal deaths

and improved links with perinatal mortality meetings. An alternative to a separate specialist

themed panel would be to allocate a neonatal theme to some CDOP meetings, with

additional membership for those meetings.

Improve collection of data on ethnicity

Explore how to capture data on level of deprivation.

Improve CDOP awareness through CDOP training sessions; increase GP and frontline staff

awareness of CDOP and their role in data completion.

Continue to map rapid response process and incorporate future audit results in future

MKSCB CDOP annual report.


14

APPENDIX 1

CDOP PANEL MEMBERSHIP

December 2015

1. Muriel Scott (Chair), Director of Public Health, Milton Keynes, Bedford Borough and

Bedfordshire Council

2. Keya Ali, Consultant Paediatrician, MK University Hospital NHS Foundation Trust

3. Sonia Brooks, Coroner’s Service Manager, Milton Keynes Council

4. Helen Craddock, MKSCB Business Manager, MKSCB

5. TBC (Was Helen Elligott) , Lead Midwife for Safeguarding and Vulnerable Families, MK

University Hospital NHS Foundation Trust

6. Ivo Haest, Consultant in Public Health, Milton Keynes Council

(From 2016 Sue Frossell will be representing Public Health on the CDOP Panel)

7. Phil Hayes, Detective Inspector, Thames Valley Police

8. Antony Heselton, Head of Safeguarding, South Central Ambulance Service (SCAS)

9. Melinda May, Head of Delivery, Milton Keynes Council Children’s Social Work

10. Lesley Mellor, MKSCB Administrator

11. Caron Morgan, CDOP Co-ordinator, MK CCG

12. Andrea Piggott, Designated Safeguarding & LAC Nurse, MK CCG

13. Tracy Rea, Bereavement Midwife, MK University Hospital NHS Foundation Trust


15

Note:

CDOP Child Death Overview Panel

LAC Looked After Child

MK CCG Milton Keynes Clinical Commissioning Group

MKSCB Milton Keynes Safeguarding Children Board

LSCB Local Safeguarding Children Board

child death overview panel...

Documents