Agenda item

Alex Hawley, Public Health Consultant/CDOP Chair, to present the Child Death Overview Panel Annual Report

Alex Hawley, Child Death Overview Panel (CDOP) Chair, and Jean Summerfield, Lead Nurse Child Death Review, presented the CDOP annual report 1^st April, 2024 to 31^st March, 2025.

 

The powerpoint presentation highlighted:-

 

Foreword and Context

-        First standalone Rotherham CDOP report

-        Transitioned oversight from Safeguarding Children Partnership to Health and Wellbeing Board

-        Administrative support now provided by Rotherham NHS Foundation Trust

-        Tribute to Sharon Pagin and welcome to Jean Summerfield

-        South Yorkshire CDOP having less frequent meetings

-        Backlog of cases reduced despite organisational changes

 

CDOP Purpose and Structure

-        The Panel included RMBC – Public Health and Social Care; TRFT – Safeguarding, Paediatrics, Midwifery; South Yorkshire Police; RDaSH; ICB; Children’s Hospice

-        Statutory function to review deaths of children (under 18 years) excluding stillbirths and planned terminations

-        To categorise cause of death

-        To consider the importance/relevance of factors present within 4 key domains – factors intrinsic to the child; factors in social environment including family and parenting capacity; factors in the physical environment and factors in service provision

-        To identify modifiable factors and prevent opportunities

-        To update the National Child Mortality Database

-        To share learning and take whatever improvement actions were identified within the system to prevent future deaths or reduce vulnerabilities

 

South Yorkshire CDOP Network

-        Covered Barnsley, Doncaster, Rotherham and Sheffield

-        Enabled identification of regional themes and trends

-        Pragmatic shift in 2024 and was now a community of interest with less frequent meetings

-        Still valuable for shared learning and data comparison

 

Rotherham CDOP 2024-25

-        8 meetings held (2 additional to reduce backlog)

-        29 cases reviewed (20 deaths in 2024/25)

-        22 active cases ongoing (delays due to inquests, reports, investigations)

-        Age distribution – highest in neonates (0-27 days)

-        Place of death – mostly hospital-based

-        Ethnicity – majority white; some Asian, Black, Mixed

-        Collaboration with agencies to improve timeliness

 

Modifiable Factors

-        4 cases (14%) had modifiable factors

-        National average 43% of cases had modifiable factors

-        Issues included – seatbelt use in modified vehicles, tracheostomy management in babies and inter-professional communication

-        National common factors – parental smoking, high maternal BMI, supervision issues, poor inter-agency communication

 

Learning and Actions

-        Themes/actions identified at CDOP inform local practice

·        Safe Sleep campaign enhancement planned

·        Task and Finish Group reviewed neonatal deaths (2021/22)

·        Most deaths linked to deprivation and chronic conditions

·        Learning shared with professionals and networks e.g. swimming lessons partnership for children with learning disabilities

-        Task and Finish Group reviewed infant/neonatal deaths.  Findings:

·        Most deaths due to prematurity/immaturity

·        Some avoidable deaths due to care delays

·        No evidence of a single factor explaining increase in numbers

 

National Trends

-        3,577 child deaths in England 2023/24 (down 4% vs previous year)

-        Child deaths at 29.8 per 199k children

·        Black children: 55.4 deaths/100k

·        Asian children: 46.8 deaths/100k

·        White children: 25.5 deaths/100k

-        Children in most deprived areas >2x death rate of least deprived.  Deprivation strongly linked to mortality

-        Infant deaths (within 1^st year of life) = 61% of total child deaths

-        Neonatal deaths (within 28 days of birth) = 42% of total child deaths

-        Infant mortality rate (under 1 year): 3.9 per 1,000 live births – a slight increase from the previous year

 

Next Steps

-        Thematic review of modifiable factors

-        Strengthen multi-agency collaboration

-        Focus on health equity and early intervention

-        Continue to work to improve the Sale Sleep offer

-        Targeted interventions for high risk groups

-        Continue backlog reduction and monitoring delays

-        Thematic review of modifiability factors

-        Influence training, service delivery and policy

-        Aim – reduce inequalities and prevent child deaths

 

Conclusion

-        CDOP delivered statutory responsibilities effectively

-        CDOP maintained rigorous review standards

-        Continued to strive towards timely and thorough reviews

-        Identified modifiable factors and learning points

-        Continued commitment to learning, prevention and family support

-        Focus on reducing inequalities and improving child outcomes

-        Persistent challenges: deprivation and inequalities

-        Commitment to prevent, partnership and family voice

-        Ongoing work to improve outcomes for children and families in Rotherham

 

Discussions ensued with the following issues raised/clarified:-

 

-        It was a statutory requirement under the Working Together to Safeguard Children guidance in England to have a CDOP and every child that died was required to have their history looked at by a Panel

-        The CDOP was in a very strong position now having processed the backlog and transitioned to the HWBB

-        The report was to be considered at the Rotherham Safeguarding Board Executive

-        The CDOP review would be focussing quite specifically on ethnicity and correlation with deprivation

-        Stillbirths were not included in DCOP reviews.  Legally a stillbirth was not defined as the death of a person.  Under UK law, a Coroner or CDOP could not review a death unless there was an independent life to begin with, however, Maternity Services within the TRFT, reviewed every stillbirth

 

Resolved:-  (1)  That the Child Death Overview Annual Report be noted.

 

(2)  That the report be approved for publication.