Executive summary
The death of any child is a tragedy. The role of the Child Death Overview Panel (CDOP) is to identify all learning from the death of any child in Leeds. The annual report of the CDOP provides a summary of learning from reviewing these deaths and recommendations for partners who can implement lessons the panel has learned from this process to prevent similar events occurring in the future.
This year, 37 deaths were reviewed by the Child Death Overview Panel and Neonatal Death Overview Panel. Up to March 2024 there were 81 cases waiting review.
Of the deaths reviewed, modifiable factors were identified in 18 cases (49%). In these instances, the factors were often overlapping and multiple. These included:
- Road traffic accident where a young inexperienced driver was driving
- Missed opportunities where children who died in a road accident had been previously in contact with social care and youth offending teams
- The impact of parental alcohol use
- Drowning in a bath
- Accidental suffocation from a nappy sack covering nose and mouth
- Accidental accident involving a pedestrian on a home driveway
- Manslaughter due to diminished responsibility and mental health problems
- Co-sleeping
- Death from a vaccine preventable disease in an unvaccinated child
- Factors related to the management of pregnancy, birth, and the early neonatal period
- Maternal smoking in three neonatal cases
- Cannabis use in a neonatal case
- One neonatal case with late booking
- Four neonatal cases with high maternal body mass index
Recommendations
- The Director of Public Health to ensure that women and families have good access to pre-conception health advice and maintain good work on smoking, healthy maternal weight, genetic awareness, mental health, drug and alcohol use, vaccination uptake, accident prevention and safe sleeping.
- The LTHT maternity service and all key partners to ensure midwifery, obstetric and neonatal staff are confident where to refer for support for mothers living in complex social conditions e.g., seeking asylum, housing, benefits, learning difficulties, maternal mental health, maternal obesity, or drug use.
- The Leeds Perinatal Quality Surveillance Partnership to continue to review the neonatal mortality rate for Leeds and consider what action is required to make improvements.
- Services and commissioners to work together to ensure that families with children have opportunities to access all the financial entitlements they are eligible for.
- The Leeds Safeguarding Executive to run the Play Safe social media campaign annually during summer; and the road safety team in Leeds City Council to continue to coordinate road safety and training by LCC and partners.
- All partners to ensure accurate recording – improvements required in recording ethnicity, smoking during pregnancy, smoking status of partners, smoking in the home, intimate partner violence, body mass index, consanguinity, and paternal age.