Child Death Overview Panel Annual Report

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 there have been two panels – a neonatal panel to review deaths of neonates and babies who never left hospital, and all over deaths which were reviewed by the CDOP.

Nineteen deaths were reviewed by the Child Death Overview Panel. There are twenty-six child deaths awaiting review. Thirty-six deaths were reviewed by Neonatal Death Overview Panel. There are thirty-five neonatal deaths awaiting review.

The CDOP identified modifiable factors and lessons learned

• Of the 19 cases reviewed this year there were modifiable factors identified in five deaths (26%). The panel also made note of lessons learnt, which were not categorised as modifiable i.e. they would have not changed the outcome for that child, but may be relevant for future cases.
• Seven cases were categorised as sudden infant deaths in childhood.
• Four children had mothers who smoked whilst pregnant. This was unknown in eight cases. This may have been as children were older when they died, and it was inappropriate to ask about smoking in pregnancy. There was smoking in the homes of 6 children who died, and for 8 deaths it was unknown if there was smoking in the home.
• Domestic violence was recorded as experienced by the family of one child who died but it was unknown for 6 deaths if there was domestic violence occurring.
• Two children were born to consanguineous parents. In two more cases it was not known if the parents were consanguineous.
• Drug use (cannabis) was reported for one parent.
• Alcohol use was reported by one child.
• One child died by hanging. Their death was recorded by the coroner as death by misadventure.

The NDOP identified modifiable factors and lessons learned

• Of the 36 cases reviewed, modifiable factors were identified in nine cases (25%).
• All babies who are born and issued a birth certificate have their deaths reviewed if they die. Seven neonatal deaths reviewed were of babies under 24 weeks gestation.
• The panel also made note of lessons learnt, which were not categorised as modifiable i.e. they would have not changed the outcome for the child.
• One neonate was born to consanguineous parents, the consanguinity status of one other child was unknown.
• The body mass index (BMI) of mothers was not recorded for nine cases. One mother was categorised underweight with a BMI below 18.5 and 8 were categorised obese with a BMI of over 30.
• Nine mothers were recorded as smoking, one mother used e-cigarettes. Smoking status of the mother was unknown in seven cases. Five partners smoked and this was unknown in 14 cases.
• The majority of mothers booked for antenatal care before 12 weeks. One booked at 17 weeks and one did not book. For eight mothers this was not recorded.
• Three families were recorded as experiencing domestic violence. Of these two had child protection plans in place. Domestic violence was not recorded for seven cases. Domestic violence was not the cause of death but a factor in the home life of these families.
• There were no recorded cases of co-sleeping, sofa sleeping, loose bedding or parental use of alcohol.
• There were two reports of parents using illegal drugs.
• It was noted when families were living in stressful conditions. There were two cases where mothers were experiencing stress with housing and benefits and one where a mother who was seeking asylum had to live apart from her partner and did not speak English. Two mothers were living with complex social factors, one mother with poor mental health and one with learning difficulties.
• One mother gave birth following discharge from unplanned antenatal care, the baby was born at home following a short labour.

Recommendations

1. The Director of Public Health to maintain good work on smoking, healthy maternal weight, consanguinity, mental health and safe sleeping.
2. The Leeds Safeguarding Executive to run the Play Safe social media campaign annually during summer with an additional focus on safety when travelling abord.
3. The road safety team in Leeds City Council to continue to coordinate road safety and training by LCC and partners including a focus on safe travel behaviour.
4. The director of Public health to ensure children and young people receive information and harm reduction messages around alcohol.
5. The Director of Public Health to ensure parents are aware of the health risks of cannabis and other substances that compromise parenting.
6. The Director of Public Health to ensure key partners supporting children and young people are aware of the risks of suicide in children and what to do if they are concerned.
7. All partners to ensure accurate recording – improvements required in recording ethnicity, smoking during pregnancy, smoking status of partners, smoking in the home, domestic violence, BMI, consanguinity and paternal age.
8. The LTHT Public Health Midwife to ensure midwifery, obstetrician and neonatal staff are confident of 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.
9. The LTHT Public Health Midwife to ensure midwifery, obstetrician and neonatal staff are confident in delivering trauma informed care.
10. The LTHT Midwifery team to ensure women and pregnant people are given safe advice when they are discharged from unplanned care to address antenatal concerns, or phone the antenatal team when in labour.

For a full copy of the CDOP Annual report please email the LSCP Business Unit with your request.