derby city and derbyshire county child death overview panel...derby city council, for carrying out...

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Derby City and Derbyshire County

Child Death Overview Panel

Annual Report 2017-2018

Alex Hawley (Acting Consultant in Public Health, Derby City Council and Chair

of CDOP)

Sereena Raju (Information Analyst, Public Health, Derby City Council)

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CDOP Annual report April 2017 – March 2018

Contents Preface ................................................................................................................................................... 4

The year in retrospect .......................................................................................................................... 6

The panel’s meetings April 2017 to March 2018 ......................................................................... 6

Confidentiality ................................................................................................................................... 9

Safe sleeping .................................................................................................................................... 9

Sudden neonatal deaths in hospital ............................................................................................ 11

Maternal obesity ............................................................................................................................. 12

Smoking in pregnancy ................................................................................................................... 13

Update on nappy sacks ................................................................................................................. 14

Update on consanguinity ............................................................................................................... 15

Taking stock .................................................................................................................................... 15

Looking forward .................................................................................................................................. 16

Analysis of Case Data ....................................................................................................................... 18

1.0 2017/18 data ........................................................................................................................... 18

1.1 Modifiability .......................................................................................................................... 23

2.0 2013/14 – 2017/18 data ........................................................................................................ 24

2.1 Trends over the five year period ...................................................................................... 24

2.2 Cumulative patterns ........................................................................................................... 27

2.3 Modifiability .......................................................................................................................... 40

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Preface

I am pleased to present our Child Death Overview Panel (CDOP) annual report for 2017-

2018. As always, the panel has gone about its work with great diligence and dedication,

always adopting an objective but sensitive approach to such emotionally and professionally

challenging subject matter, with undiminished zeal for learning and applying important

lessons, to benefit and protect other (and future) Derbyshire children. It is worth restating

Ofsted’s judgement of the work of the panel from its inspection of the Derby Safeguarding

Children Board in early Spring of 2017, in which it found that the panel was doing “all that it

can to ensure that awareness is raised in the local community in the hope of preventing

further deaths.”

I certainly would like to take the opportunity I have in writing this preface to offer my personal

thanks to everyone who has attended CDOP panels during the year, or who has contributed

behind the scenes. I feel extremely privileged to have been the Chair of this panel for nearly

two years, given the high calibre and dedication of all its members from across a wide range

of disciplines. Thanks to everyone who has contributed Form Bs, compiled agendas,

presented cases, taken minutes, followed up actions, engaged in discussion, or represented

CDOP at other meetings.

During the year, some long-serving stalwarts of the panel have moved on, and I would

therefore particularly like to register huge thanks and best wishes to DCI Malcolm Bibbings,

Dr Helen Jacques, Sue Rucklidge, and Kathy Webster.

I am very confident that Juanita Murray, Kathy Webster’s successor as Designated

Safeguarding Nurse in the north, and also my successor as incoming Chair, will benefit from

the same level of commitment and support from her CDOP colleagues that I have enjoyed,

and will successfully take the work of the panel forward. I would also like to extend my

thanks to Michelina Racioppi, who will shortly be stepping down as Vice-Chair, and I am very

grateful to Anne Hayes for stepping up to take on that role and so ensure that Public Health

continues to have a strong voice in the work of the panel.

It is clear that there are some important challenges in the year ahead, as national guidance

and local governance changes come into force. At the time of writing, we are still awaiting

the publication of the final Child Death Review statutory guidance (updating the consultation

version that was published in October 2017). In the meantime, however, July saw the

publication of the new ‘Working Together’ guidance, which means that the clock is already

ticking for agreeing our revised local safeguarding arrangements, including CDOP and other

processes of child death review.

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We also now know that the long-awaited and keenly anticipated National Child Mortality

Database (NCMD) is now in development. NHS England has commissioned the University

of Bristol, in collaboration with University of Oxford, UCL Partners and QES to develop the

NCMD, to which all CDOPs will eventually submit data for central analysis, with the

expectation of deeper understanding of patterns and trends. The project is funded for four

years from April 2018, with these key milestones expected:

Year 1: Develop and pilot the IT systems required to support data capture and create the

central database structure

Year 2: Commence national data collection and publish the outcomes from the pilot

Year 3: Annual and Thematic Reports

Year 4: Annual and Thematic Reports

To better enable such national analysis, it seems inevitable that this project will require some

further standardisation across CDOPs in the way that components of reviews are currently

interpreted.

In the meantime, we always endeavour to achieve thoroughness and consistency in the

decisions we make in the panel and the way that this is recorded and coded, and to be

constantly vigilant for any emerging local themes or trends, so that we can respond

accordingly. A key component of that is the analysis we carry out every year and present in

this report. I hope that you find it both informative and interesting, notwithstanding the grim

nature of the topic .

If this report raises any further questions or you would like to make any comments please do

not hesitate to contact Rachel Turley for additional information via

[email protected]

I am indebted to Sereena Raju, Information Analyst in the Public Health Department at

Derby City Council, for carrying out the analysis of CDOP data for this report, and setting this

out so clearly not only for the last financial year (2017/18), and also for the last five years

(2013/14 to 2017/18). Given the number of historic cases that have come to panel this year,

I was keen to include this look-back analysis, and I am very grateful to Sereena for agreeing

to take on this extra work. Her analysis begins on page 17.

Finally, I would like to offer one final personal vote of thanks to Rachel Turley. It has been a

pleasure and a privilege to work closely with Rachel, and I am very grateful for her constant

good humour and personal support at all times.

Alex Hawley, Acting Consultant in Public Health, Chair of Derby City and Derbyshire County Child

Death Overview Panel

mailto:[email protected]

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The year in retrospect

The panel’s meetings April 2017 to March 2018

The number of cases presented at each panel sitting are set out below, along with the

number of representatives present at each meeting. Note that the August meeting was

cancelled due to availability, and March was used as an additional neonatal panel meeting

(neonatal panels shaded in blue, full CDOP panels in green), rather than a development

session. In November, there were no Lead presenters available, meaning no cases could be

presented, but the meeting went ahead as a development and communication session, with

a focus on the consultation on ‘Working Together’, which concluded in December.

Cases

presented

Number

attending

April 5 8

May 2 19

June 4 15

July 10 10

August Cancelled

September 6 17

October 12 10

November

15

December 6 20

January 13 16

February 5 19

March 14 16

Overall, the number of cases presented (not all were closed) to each neonatal panel tends to

be larger, but usually with a slightly smaller attendance, owing to the greater medical focus

of issues of concern, and perceived reduced need for wider partnership discussion. In total,

54 cases were presented to five neonatal panel sittings, while 23 cases were presented to

five full CDOP panels. All the panel sessions last between three and three and a half hours,

and also include sign-off of minutes, follow-up of actions, key communications from other

panels and organisations, and discussions relating to developing the work of the panel and

the wider child death review processes. Allowing for this, it is likely each neonatal case will

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have occupied an average of about 15 minutes, and each non-neonatal case probably about

30 minutes of panel time.

We expect attendance as far as possible to represent our core membership

organisations/professions, which currently are Derby City Council Children’s Services,

Derbyshire County Council Children’s Services, Southern Derbyshire CCG, North

Derbyshire CCG (also covering Erewash CCG and Hardwick CCG), Derbyshire

Constabulary, Chesterfield Royal Hospital NHS Foundation Trust, University Hospitals of

Derby and Burton NHS Foundation Trust, Derbyshire Community Health Services NHS

Foundation Trust, Derbyshire Healthcare NHS Foundation Trust, and Public Health on

behalf of Derby City Council and Derbyshire County Council.

We keep our membership under review, and one of the successes of this year has been the

regular attendance of a designated GP, which has proved very helpful for ensuring reviews

are fully informed.

Attendance from core members has been good, with the main concern being Children’s

Social Care from both City and County. Discussions about trying to improve this have been

positive, despite obvious resource and capacity constraints, and give grounds for optimism

about an improved level of attendance looking forward.

In total, some 45 people attended at least one CDOP panel meeting in 2017/18, and I would

like to extend thanks to all those listed below who gave their time in this way to help us learn

from tragedy with the ambition of preventing avoidable future child deaths.

Adrian Thorpe, Business Support, Derby City Council

Adrienne Williams, Team Manager, Children’s Services, Derbyshire County Council

Alex Hawley (Chair), Specialty Registrar in Public Health, Derby City Council

Beth Pascall, Paediatric Registrar (observer)

Carolyn Langrick, Maternity Matron, RDH (UHDB)

Colin Barker, Lay Representative

Emily Preston, Student Nurse (observer)

Emma Devitt, Bereavement Midwife, RDH (UHDB)

Emma Williams, Derbyshire Constabulary

DI Graham Prince, Derbyshire Constabulary

Dr Helen Jacques, Consultant Paediatrician, DHCFT

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Jan Dawson, Head of Service, DCHS

Jane Haslam, Head of Midwifery, RDH (UHDB)

Dr Jenny Evennett, Designated Doctor for Safeguarding, RDH (UHDB)

Dr Jeremy Gibson, Named GP for Safeguarding

Dr John McIntyre, Consultant Neonatologist, RDH (UHDB)

Juanita Murray, Designated Nurse (observer)

Judy McCulloch, Specialist Midwife in Drugs & Alcohol (guest speaker)

Karen Barden, Acting Head of Child Protection, Children’s Services, Derbyshire County Council

Kate James, Senior Midwife, RDH (UHDB)

Kate Thorpe, School Nurse, DHCFT

Kathy Webster, Designated Nurse, NDCCG

Kayleigh Jennison, Paediatric Liaison Nurse, DHCFT

Dr Lizzie Starkey, Consultant Paediatrician, RDH (UHDB)

DCI Malcolm Bibbings, Derbyshire Constabulary

Dr Mengyan Lu, Foundation Doctor, placed at Derby City Public Health (guest speaker)

DCI Michael Cooper, Derbyshire Constabulary

Michelina Racioppi, Designated Nurse, SDCCG

Dr Nicola Medd, Consultant Paediatrician, CRH (CRHFT)

Dr Onajite Etuwewe, Consultant Paediatrician, DHCFT

DI Paul Bullock, Derbyshire Constabulary

Dr Peter Woodcock, Named GP for Safeguarding

Rachel Hunt, Student Health Visitor (observer)

Rachel Turley, CDOP Co-ordinator, DHCFT

Rebecca Siviter, Midwife in Drugs and Alcohol (guest speaker)

Rosie Sheffield, Child Protection Manager, Children’s Services, Derby City Council

Sarah Fitzgerald, Named Nurse, DCHS

Shirley Adams, Minute-taker, Business Support, Derby City Council

Sinder Gill, Derbyshire Constabulary

Sue Earnshaw, Service Line Manager, Health Visiting, DHCFT

Sue Gittins, Named Nurse, CRH (CRHFT)

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Sue Rucklidge, Bereavement Midwife, RDH (UHDB)

DI Toby Fawcett-Greaves, Derbyshire Constabulary

Vanessa Roberts, Healthy Child Programme Lead, Welbeck Road Medical Centre

Zoe Rudderforth, Safeguarding Advisor, DHCFT

Confidentiality

Every CDOP Panel meeting deals with personal information of the highest possible

sensitivity, and always begins with everyone in attendance committing to a confidentiality

declaration that appears at the top of every agenda:

With this in mind, this report will obviously avoid levels of detail that might risk disclosure, but

will set out some of the themes that have emerged during the year, usually through a mixture

of individual case reviews and wider discussion relating to current topics of interest or

prompted by items of communication received by the panel from other CDOPs or other

agencies with a concern for child safety.

Safe sleeping

In addition to reinforcing the advice regarding safe sleeping practices and factors in the

household that increase the risk of SIDS (especially parental smoking and drinking), there

has been considerable discussion arising from new products coming onto the market that

make unsubstantiated claims for safety. Baby hammocks and poddle pods featured in the

presentation to our CDOP seminar by RoSPA (as reported in last year’s annual report). In

addition to these, we heard this year about sleep positioners, which featured in the national

news in October 2017, when some UK retailers dropped such products in response to a

statement from a US Regulator about the risk of suffocation that they pose.

CDOP Confidentiality Declaration

Information discussed by the group is strictly confidential and must not be disclosed to third

parties without the agreement of the partners of the meeting. A clear distinction should be

made between fact and opinion.

All agencies should ensure that the minutes are retained in a confidential and appropriately

restricted manner.

The minutes will aim to reflect that all individuals who are discussed at these meetings should be

treated fairly, with respect and without improper discrimination. All work undertaken at the

meetings will be informed by a commitment to equal opportunities and effective practice issues

in relation to race, gender, sexuality and disability.

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Derby and Derbyshire CDOP does not support the use of any such products that create an

additional risk of head-covering. We would seek to reinforce the message from the weight of

available evidence, which is that the safest way for a baby to sleep is on a firm flat mattress,

with no pillows, toys, cot bumpers or indeed sleep positioners.

We have also discussed concerns relating to home assembly of cots, especially when

adjusting (e.g. the height of the mattress), reassembling a cot that has been stored flat, or

assembling a cot purchased or acquired second hand. In such circumstances, concerns

arise where manufacturer’s instructions may no longer be available and where key fixings

may have been mislaid.

We are seeking advice from the RoSPA, CAPT and the Lullaby Trust regarding both trading

standards applying to resale of such items, and a comprehensive guide for parents. In the

meantime, our advice would always be to check for a cot that meets the British Standard for

safety – BS EN 716. Additionally, check that the dimensions of the cot meet safety standards

– at least 49.5cm deep; vertical bars with spacing of 4.5cm to 6.5cm. Do not use a second

hand mattress, but purchase one new that meets BS 1877, and fits well with a gap of less

than 4cm between the edge of the mattress and the sides of the cot.

Another area of concern with respect to safe sleeping is when a baby sleeps away from the

parental home, especially in the home of grandparents. It is obviously far more difficult for

our universal health visiting service to exert influence outside the family home. With this is

mind our ‘Keeping Babies Safe’ sub-group has produced a leaflet specifically for

grandparents.

Safe sleeping in the maternity ward setting has also been a topic of discussion, and we were

pleased to hear of an intervention at Royal Derby Hospital, where an infographic has been

developed and put on prominent display. This uses the acronym BASIC - BAby Safe In Cot,

prior to new mothers getting some sleep. This looks like an excellent innovation that helps to

keep babies safe in hospital and also instils good sleep behaviour at the earliest possible

opportunity.

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BASIC infographic. Reproduced with kind permission of Jane Haslam, Royal Derby Hospital

Sudden neonatal deaths in hospital

Related to concerns around safe sleeping in hospital is the incidence of deaths resulting

from sudden unexpected postnatal collapse. The Panel has sought to understand what

might lie behind such deaths, but the current expert view is that between 40% and 50% of

such deaths remain unexplained. This is clearly an area where the national child mortality

database is likely to prove of value in identifying patterns in such deaths evident across a

national dataset. We have sought a better understanding of the national picture by seeking

information from other CDOPs across the country, but this has not yet provided any insights.

According to a paper which analysed data from the UK via the British Paediatric Survey Unit

(BPSU) [1], the incidence of such collapse within the first 12 hours of life is 5/100,000 term

live births, with a mortality of 1/100,000 term live births, but other studies suggest the

incidence of collapse could range between around 3/100,000 in the first 24 hours [2] and 27

per 100,000 within the first three days [3], and also that up to 50% of cases of collapse may

result in death [4].

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A number of risk factors are commonly identified in the literature, which include being a first-

time mother; when initiating breastfeeding; when the baby is in a prone position; during skin-

to-skin contact; cobedding, and mother and baby being left alone during first hours following

birth [4], in addition to factors that might identify a baby at greater risk (e.g. low apgar score),

or indeed where a mother is recovering from an exhausting labour. This is clearly an area

where more understanding is required, but it already seems clear that surveillance and

vigilance in the first hours after birth would be an important preventive strategy.

With some relation to this, the Panel was pleased to hear of Royal Derby Hospital’s

innovation to ensure good temperature regulation, and to alert clinical staff (and parents) to

be more vigilant where babies have higher risk, indicated by different coloured knitted hats.

Cindy Meijer, Risk Support Midwife with baby and coloured hats, and the ‘Goldilocks’ poster included in Royal

Derby Hospital’s ‘Newborn Thermal Care Safety Bundle’. Reproduced with kind permission of Cindy Meijer and

Jane Haslam, RDH

Maternal obesity

In April 2017, we received a question from Cumbria’s CDOP seeking examples from around

the country where maternal obesity had been identified as a modifiable factor (i.e. a factor

that could have been modified and may have led to a different outcome). This prompted

discussion both about how routinely we would collect information about the BMI of the

mother through our standard Form Bs, and also how confident we could be to attribute some

level of contribution or causality to a mother’s weight. Cumbria was particularly interested in

cases of prematurity.

The majority of neonatal deaths that CDOP reviews are preterm births (

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low. In the UK about 60,000 preterm babies are born each year, of which about 3000 are

extremely premature, more than 50% of whom would now be expected to survive [5].

Mothers with BMI>40 may have three times the risk of delivering extremely prematurely [6],

but such mothers only account for about 2% of pregnancies [7]. A quick rough calculation

suggests overall, there may be around 100-120 additional extremely premature births

associated with very high maternal BMI (>40) in the UK each year, and therefore perhaps 50

additional deaths. In Derbyshire, we might therefore only expect to see something like 7 or 8

such deaths over a ten year period.

Perhaps of more importance than engaging in discussion about levels of contribution for

individual cases is simply to ensure that we collect the data in the first place, so that we can

get more reliable population-level data regarding incidence and risk. We would therefore

wish to see maternal BMI become a standard information item within the national child

mortality database.

Smoking in pregnancy

The smoking habits of parents are routinely collected for CDOP review, and are often a

source of much discussion in relation to both neonatal deaths and SIDS cases. The

association between smoking in pregnancy and risks of prematurity, low birth weight and

indeed SIDS are well established. Nevertheless, it is less than straightforward to identify

smoking as a modifiable factor in an individual case, when basing this simply on population-

level risk, especially when other potentially causal factors are identified. In effect, we know at

a population level that a proportion of preterm births are likely to be attributable to smoking in

pregnancy, but it does not always follow that where a neonatal death has occurred that the

mother’s smoking habit contributed to the outcome.

The panel therefore tries to take a nuanced approach in looking at the specific

circumstances of each case and attempting to identify where smoking is a modifiable factor

that contributed to the death, or the slightly lesser implication of being a factor that

contributed to vulnerability, or indeed is simply an incidental piece of information. This has

often been a point of considerable debate and it is certainly not a consensus view of the

panel that this approach is preferred over a more de facto approach that smoking should

always be seen as contributory.

One potential difficulty that may arise from this approach is one of consistency – consistency

over time, e.g. as more evidence emerges associating smoking with particular conditions or

complications, and consistency with other CDOPs.

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In April 2018, the Derby Telegraph ran a news item based exclusively on data reported in

last year’s CDOP annual report, which had the headline, “Second-hand smoke played part in

eight Derbyshire child deaths”, based on the fact that we had identified eight cases during

the year where we had decided on the balance of probability that smoking by a parent or

carer was considered to have contributed to vulnerability. Whilst it is pleasing that the local

press has been moved to raise what is clearly a significant public health concern, their

reporting of an exact figure in this way, based on the work of the CDOP panel, is effectively

spurious, given the absence of a scientific method of classification.

As with maternal obesity, the more important factor for analytical purposes is really the fact

that smoking habit data is collected, rather than how it was interpreted in individual cases.

As work continues on developing the national child mortality database, some thought needs

to be given to how this data is collected – e.g. whether number of cigarettes smoked needs

to be recorded, or indeed if vaping habit needs now to be collected. Ultimately, we would

also expect the national database to have a nationally consistent approach to how factors

are categorised, and we would certainly appreciate at least some consistent guidance on

this.

Strongly related to this is the use of other drugs by a parent, and some better understanding

of the risks associated with smoking cannabis, for example, when compared with tobacco.

We were fortunate in this respect in to receive a presentation to the January neonatal panel

from Judy McCulloch, Specialist Midwife in Drugs & Alcohol. She was able to tell us that

cannabis has been shown to be a risk for SIDS, and also told us about birth abnormalities

and early miscarriages associated with use of M-CAT and Black Mamba, but overall

confirmed that more research is needed in this area, particularly in respect of current trends

for increasing use in pregnancy of cocaine, polypharmacy and new psychoactive

substances, and indeed vaping.

Update on nappy sacks

Last year’s report described how Derby and Derbyshire CDOP

continued to contribute to the national debate on the risk

posed by nappy sacks, and in particular efforts co-ordinated

by RoSPA to exert influence on retailers, suppliers and trading

standards. During the year there have been some very

encouraging developments. In September RoSPA and the

British Retail Consortium published a guideline, advising on

https://www.rospa.com/rospaweb/docs/campaigns-fundraising/nappy-sack-guidelines.pdf

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warning labelling requirements for both back and front of packets, and seeking the

development of a safety pictogram to be displayed at the point of extraction.

The guidelines are not prescriptive, but there appears to have been a positive response from

the major retailers. In December, Morrisons announced they would become one of the first

retailers to put warning labels onto the packaging, and since then many other major retailers

have committed to adding warning labels to the front of packaging.

Update on consanguinity

In December and January, a series of four genetic literacy training sessions were delivered

by Dr Aamra Darr to a total of 61 healthcare professionals, which received excellent

feedback from delegates. The cost of the training was met by one-off funding obtained from

NHS England, as this fitted well with their safeguarding priorities.

In February, CDOP heard from Dr Mengyan Lu, a second year Foundation doctor on rotation

with Derby City Council’s Public Health team. Having benefited from the training, in early

February she put it into immediate use, as she helped deliver a community workshop on

cousin marriage on behalf of CDOP to a group of Pakistani muslim women resident in the

Normanton area of Derby. The workshop included a presentation on some of the risks

associated with cousin marriage, a lively discussion in which attendees were very willing to

share personal experience and stories from within their kinship groups, and a discussion on

producing a local information leaflet, based on the one used in Bradford. The consensus was

that such a leaflet would be worthwhile and could be made available in community centres,

mosques, GPs, etc.

Taking stock

During the year, both the CDOP Co-ordinator and the Lead Reviewers looked back through

their records to identify any outstanding cases that had not yet come to the Panel for review.

This uncovered a large number of quite historic cases (mostly neonatal) that still needed a

Panel review. This prompted a one-off concerted effort to get up to date, and also a review

of processes to ensure that a more rapid turnaround time could be assured and that there

could not be a recurrence of such a backlog in the future.

CDOP is very grateful to all its reviewers for the additional effort required during the course

of the year to get ourselves up to date. We decided to use our session in March, normally

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reserved for a development workshop, as an additional neonatal panel to assist this process.

Happily, by the end of the session in April 2018, our cases were largely up to date, and from

this point on, we have agreed to include the date of notification for each case on the agenda,

in order to continue to prioritise older cases for panel review.

Given the large number of historic cases that have been reviewed during the year, it is timely

to include some revised time series analysis in the report, looking back over the last five

years.

Another innovation this year to try to reduce potential for delay has been the use of a

checklist for each case considered at review, to ensure that all the relevant information (e.g.

Form Bs) has been received prior to the case being presented, and to ensure clarity about

follow-up actions required, and whether a particular case has been kept open pending any

such follow-up. This checklist is now included in the minutes for every case presented.

Looking forward

One reason for getting ourselves up to date and for introducing new checks and processes

is the ongoing changes to ‘Working Together’ and its associated changes in guidance for

child death reviews. Amongst other things, the draft guidance set out an ambitious

expectation that cases should be able to complete the entire review process within six

months.

At the time of writing, we have the new ‘Working together to safeguard children’ guidance,

published in July 2018, which includes a chapter specifically on statutory requirements for

child death reviews and an outline of the responsibility of partners. However, final detailed

guidance relating to child death reviews is still awaited.

Rather than waiting for this guidance to be published, we will be continuing to review our

processes, based on the chapter in ‘Working together’ and the draft consultation version of

the guidance published in October 2017. There are many considerations for us to work

through: how we meet all the various stages of review in a timely fashion – immediate

decision making and notifications, investigation and information gathering, the child death

review meeting, and finally independent review by CDOP panel. Given that we will have no

additional capacity, this will require some smart thinking about our processes and tools and

how we share out responsibilities. In respect of responsibilities, we are aware of the need to

provide the role of ‘Designated Doctor for child deaths’, which looks entirely new, but which

will have to be accommodated within existing resources.

The draft guidance suggests that some child deaths may be best reviewed at a themed

meeting, where there are a number of cases with a similar cause or group of causes. We

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have routinely considered all our neonatal cases separately from other cases, largely for

convenience, but have not yet intentionally grouped cases by theme. We are intending to

trial this approach in November this year, when we will be reviewing a number of cases that

broadly relate to adolescent mental health and behaviour, and will extend the membership of

the panel to include people with particular relevant expertise. It is hoped that this will prove

beneficial in respect of the discussion and lessons learnt. Any benefits of such an approach

on an ongoing basis will need to be balanced against the potential delay that it introduces

into the review process, if particular cases need to be held back for consideration at a

themed meeting.

The new guidance doubtless presents a number of challenges, but CDOP has always had a

very committed body of people behind it, who as Ofsted recognised do all that they “can to

ensure that awareness is raised in the local community in the hope of preventing further

deaths”.

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Analysis of Case Data

The analysis of data is divided into two sections. The first provides an overview of data from

the latest year (2017/18). The second provides a cumulative analysis of the previous five

years (2013/14 – 2017/18).

1.0 2017/18 data

During 2017/18, 73 cases were reviewed by the panel1. These were assessed for

modifiability and any relevant environmental, extrinsic, medical or personal factors that may

have contributed to the child’s death.

Table 1 provides a breakdown of reviewed cases grouped by local authority of residence.

Table 1: Number and proportion of deaths reviewed grouped by local authority of

residence

Local authority of residence

Number of deaths Proportion of deaths

Derby City 24 32.9%

Amber Valley 9 12.3%

South Derbyshire 9 12.3%

Erewash 8 11.0%

Bolsover 5 6.8%

Chesterfield

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Table 2 provides an overview of the events reviewed by the panel.

Table 2: Summary of events reviewed by the panel

Event Derby city Derbyshire

county Derby city %

Derbyshire county %

Neonatal death (B2) 12 19 50.0% 44.2%

No data (blank) 9 14 37.5% 32.6%

Sudden unexpected death in infancy (B4)

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Overall, perinatal/neonatal events were the most common type of event reviewed. Within the

city, these comprised a marginally higher proportion of cases than those in the county.

Table 4 provides a breakdown of the reviewed deaths in the city and county grouped by age

category.

Table 4: City-County split of reviewed deaths grouped by age category

Age group Derby city Derbyshire

county Derby city %

Derbyshire county %

0-27 days 18 27 * 62.8%

28-364 days 5 8 * 18.6%

1-4 years

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Table 6 provides an ethnic breakdown of the number and proportion of reviewed cases.

Table 6: Number and proportion of reviewed cases grouped by ethnicity

Ethnic group Number of reviewed

cases Percentage of

reviewed cases

White British 33 45.2%

No data (blank) 23 31.5%

Not stated 12 16.4%

Pakistani

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The Indices of Multiple Deprivation (IMD) 2015 score provides a relative measure of

deprivation within an area. Thus the higher the deprivation score, the more deprived the

area. Public Health England provide adjusted IMD 2015 scores that align with the 2011

lower super output areas (LSOAs) in England:

https://www.gov.uk/government/statistics/english-indices-of-deprivation-2015

The IMD scores for the LSOAs across Derbyshire were sorted from the most to the least

deprived, before being divided into local deprivation quintiles. This was used to form a

lookup for the IMD scores extracted within the dataset.

Table 8 provides a summary of the number and proportion of cases across each deprivation

quintile.

Table 8: Number and proportion of reviewed cases grouped by local deprivation

quintile

Local deprivation quintile Number of cases Proportion of cases

1 32 45.1%

2 12 16.9%

3 10 14.1%

4 7 9.9%

5 10 14.1%

Total 71 100.0%

In 2017/18, almost half of the cases (n=32; 45.1%) were from the most deprived quintile.

Table 9 provides an overview of reviewed cases grouped by contributory factors.

Table 9: Reviewed cases grouped by contributory factors

Contributory factor Number of reviewed cases Proportion of all

reviewed cases (73)

Acute/sudden onset illness 61 83.6%

Prior medical intervention 30 41.1%

Smoking by parent/carer in household 21 28.8%

Smoking by mother during pregnancy 20 27.4%

Other chronic illness 17 23.3%

Prior surgical intervention 12 16.4%

Access to health care 8 11.0%

Alcohol/substance use by a parent/carer 8 11.0%

Domestic violence 6 8.2%

Motor impairment 5 6.8%

Sensory impairment 37 50.7%

Housing issues

https://www.gov.uk/government/statistics/english-indices-of-deprivation-2015

23

Other disability or impairment

Emotional/behavioural/mental health condition in child

Epilepsy

Consanguinity

Co-sleeping

Learning disabilities

Child abuse/neglect

Bullying

Gang/knife crime

Poor parenting/supervision

Asthma

Allergies

Total number of contributory factors 225

The most common reported contributory factor was acute/sudden onset illness. This was

followed by prior medical intervention (n=30; 41.1%) and smoking by a parent/carer (n=21;

28.8%).

1.1 Modifiability

Table 10 provides a high-level summary of modifiability.

Table 10: Modifiability of reviewed cases

Modifiability Number of cases Proportion of

cases

No modifiable factors identified 59 83.1%

Modifiable factors identified 12 16.9%

Total 71 100.0%

Modifiable factors were identified in 12 of the cases that were reviewed (16.9%).

Table 11 provides a gender breakdown of the modifiability of the cases in 2017/18.

Table 11: Number and proportion of cases grouped by modifiability and gender

Gender No modifiable

factors identified Modifiable factors

identified No modifiable

factors identified % Modifiable factors

identified %

Female 25 6 43.9% 50.0%

Male 32 6 56.1% 50.0%

Total 57 12 100.0% 100.0%

24

There was an equal gender split between cases in which modifiable factors were identified.

Table 12 provides a breakdown of the cases grouped by modifiability and local deprivation

quintile.

Table 12: Number and proportion of cases grouped by modifiability and local

deprivation quintile

Local deprivation quintile

No modifiable factors identified

Modifiable factors identified

No modifiable factors identified %

Modifiable factors identified %

1 24 7 41.4% 58.0%

2 11

25

*Cases without a valid date of birth or date of death were excluded from this age breakdown, which

will mean that the total adds up to less than 307.

Overall, the majority of cases were based on children aged 1 and under (n=216; 70.8%).

However, this has become increasingly skewed in the latest year (2017/18).

Figure 1 provides an overview of trends in the overall rate of cases, those aged 1 and under

and 2-17.

Figure 1: Trends in the rate of cases per 1,000 between 2013/14 – 2017/18

Figure 1 reinforces the recent increase in the rate of cases amongst children aged 1 and

under. However, it should be noted that the confidence intervals are relatively wide.

Conversely, there has been a marginal decline in the rate of incidents in the latest year.

26

Figure 2 provides a gender breakdown of trends in the rate of cases over the five years.

Figure 2: Gender breakdown of trends in the rate of cases between 2013/14 – 2017/18

Between 2013/14 and 2015/16, the rate of deaths amongst males aged 0-17 was

consistently higher than that of females. However, the magnitude of this difference appears

to have reduced in the latest year. It should also be noted that across all years, the rate of

male and female deaths are not significantly different from each other due to the wide

confidence intervals.

27

2.2 Cumulative patterns

Table 14 provides a breakdown of reviewed cases grouped by local authority of residence.

Table 14: Number and proportion of deaths reviewed grouped by local authority of

residence

Local authority of residence

Number of deaths Proportion of deaths

Derby City 109 35.5%

Amber Valley 34 11.1%

South Derbyshire 23 7.5%

Erewash 22 7.2%

Bolsover 20 6.5%

Chesterfield 17 5.5%

North East Derbyshire 16 5.2%

High Peak 11 3.6%

Derbyshire Dales 10 3.3%

Glossop

28

Figure 3: Crude rate of deaths per 1,000 in children aged 1 and under

© Crown Copyright and Database Rights Ordnance Survey 2018. License Number: 100024913

*A key of the labelled wards is available in appendix 1.

Figure 3 suggests that some areas of the county were affected by the highest rate of deaths,

particularly Bolsover and North East Derbyshire. Barms (in High Peak) and Clifton and

Bradley (in Derbyshire Dales) were affected by the highest rate of deaths (11.7 and 11.6

respectively). This was closely followed by Barlborough in Bolsover (11.5). Many wards

within Derby city were affected by smaller, nonetheless concerning rates.

Figure 4 below provides a district-level breakdown of the rate of cases reviewed for children

aged 1 and under.

29

Figure 4: Crude rate of reviewed deaths per 1,000 local authority-level population in children aged 1 and under

30

The highest rate of reviewed deaths were from Derby city (2.40), followed by Amber Valley

(1.95) and Bolsover (1.72). However, the confidence intervals are relatively wide, which

indicates some random variation in the data.

Figure 5 provides a ward-level breakdown of the rate of deaths amongst children aged 2-17

over the five year period.

Figure 5: Crude rate of deaths per 1,000 in children aged 2-17

© Crown Copyright and Database Rights Ordnance Survey 2018. License Number: 100024913

*A key of the labelled wards is available in appendix 2.

31

As echoed previously, there were wide variations in the rate of deaths amongst this age

group across Derbyshire. The Ashover ward in North East Derbyshire had the highest rate of

deaths amongst 2-17 year-olds (1.66). This was followed by Hatton in South Derbyshire

(0.86) and Hulland in Derbyshire Dales (0.72).

Figure 6 below provides a district-level breakdown of the rate of cases reviewed for children

aged 2-17.

32

Figure 6: Crude rate of reviewed deaths per 1,000 local authority-level population in children aged 2-17

33

Figure 6 demonstrates that the highest rate of reviewed deaths amongst children aged 2-17

were from Derby city (0.304). This was followed by Amber Valley (0.224) and Bolsover

(0.216). However, these should also be interpreted with caution due to the relatively wide

confidence intervals.

Table 15 provides a breakdown of the events reviewed by the panel over the five year

period.

Table 15: Summary of events reviewed by the panel

Event Derby city

Derbyshire county

Total (including

outside areas and those with no data)

Derby city %

Derbyshire county %

Overall %

Neonatal death (B2) 54 61 134 49.5% 38.4% 43.6%

Known life limiting condition (B3) 17 21 45 15.6% 13.2% 14.7%

No data 9 19 * 8.3% 11.9% *

Other 8 19 * 7.3% 11.9% *

Sudden unexpected death in infancy (B4) 8 21 34 7.3% 13.2% 11.1%

Fire and burns (B7) 6

34

Table 16: City-County split of the category of deaths

Category of death Derby city Derbyshire

county

Total (including

outside areas and those with no data)

Derby city %

Derbyshire county %

Overall %

Perinatal/neonatal event 46 56 120 42.2% 35.2% 39.1%

Chromosomal, genetic and congenital anomalies 23 26 56 21.1% 16.4% 18.2%

Malignancy 8 13 * 7.3% 8.2% *

Deliberately inflicted injury, abuse or neglect 7

35

Table 17: Number and proportion of reviewed deaths grouped by age category, and

percentage of children as a proportion of the 0-17 population of Derbyshire between

mid-2013 – mid-2017 (ONS, 2014-2017)

Age group Number of deaths Percentage of reviewed

deaths

Percentage of all children in Derbyshire as a proportion of 0-17

population

0-27 days 151 49.5% 5.3%

28-364 days 54 17.7%

1-4 years 30 9.8% 22.6%

5-9 years 21 6.9% 28.4%

10-14 years 25 8.2% 26.6%

15-17 years 24 7.9% 17.1%

Total 305 100.0% 100.0%

Although children under 1 comprise the lowest percentage of the 0-17 population (5.3%),

this group had the highest proportion of deaths (67.2%).

Table 18 provides a breakdown of the reviewed deaths in the city and county grouped by

age category.

Table 18: City-County split of reviewed deaths grouped by age category

Age group Derby city Derbyshire

county Derby city %

Derbyshire county %

0-27 days 59 74 54.1% 46.5%

28-364 days 20 28 18.3% 17.6%

1-4 years 11 15 10.1% 9.4%

5-9 years 8 11 7.3% 6.9%

10-14 years 7 16 6.4% 10.1%

15-17 years

36

Table 19: Number and proportion of reviewed deaths grouped by gender

Gender Number of

deaths Proportion of

reviewed cases

Proportion of 0-17 population (mid-2013 – mid 2017)

Male 176 58.9% 51.1%

Female 123 41.1% 48.9%

Total 299 100.0% 100.0%

Table 19 highlights a higher proportion of reviewed cases amongst males (n=176; 58.9%).

This was not representative of the local population, for which there was a virtually equal

gender split (mid-2013 – mid 2017; ONS).

Table 20 provides an ethnic breakdown of the number and proportion of reviewed cases.

Table 20: Number and proportion of reviewed cases grouped by ethnicity

Ethnic group Number of

deaths Percentage of

deaths

White British 164 53.4%


Pakistani 17 5.5%

White Other 15 4.9%

Not stated 15 4.9%

Other ethnic group 8 2.6%

Indian 5 1.6%

Asian Other

37

Table 21 provides a summary of the location at the time of death.

Table 21: Number and proportion of reviewed cases grouped by location

Location at the time of death Number of

deaths Proportion of

deaths

Acute hospital

Acute hospital neonatal unit 79 25.7%

Acute hospital paediatric intensive care unit 58 18.9%

Acute hospital other 27 8.8%

Acute hospital emergency department 23 7.5%

Acute hospital paediatric ward 11 3.6%

Acute hospital unknown dept 6 2.0%

Acute hospital adult intensive care unit

38

Table 23 provides a breakdown of cases where the child had surviving siblings.

Table 23: Number and proportion of cases where there were surviving siblings

Surviving siblings Number of

cases Proportion of cases


Yes 42 13.7%

No 7 2.3%

Grand Total 307 100.0%

Across the majority of cases, no data was recorded for this field (n=258; 84%). Across 42

cases (13.7%), there were surviving siblings.

Table 24 provides an overview of cases where safeguarding issues had been identified.

Table 24: Number and proportion of cases where safeguarding issues were identified

Dimension Number of cases

Proportion of all deaths

Child or family known to social care 22 7.2%

Child or family known to police 32 10.4%

Child or family known to both social care and police 11 3.6%

Safeguarding issues were identified in a minority of cases. Across 11 cases (3.6%), serious

concerns had been identified by both social care and the police.

Table 25 provides an overview of reviewed cases grouped by contributory factors.

39

Table 25: Reviewed cases grouped by contributory factors

Contributory factor Number of reviewed

cases

Proportion of all reviewed cases

(307)

Acute/sudden onset illness 231 75.2%

Prior medical intervention 90 29.3%

Other chronic illness 80 26.1%

Access to health care 59 19.2%

Smoking by parent/carer in household 51 16.6%

Prior surgical intervention 50 16.3%

Smoking by mother during pregnancy 46 15.0%

Motor impairment 37 12.1%

Domestic violence 30 9.8%

Learning disabilities 26 8.5%

Alcohol/substance misuse by a parent/carer 23 7.5%

Epilepsy 23 7.5%

Sensory impairment 20 6.5%

Housing issues 19 6.2%

Emotional/behavioural/mental health condition in child 19 6.2%

Poor parenting/supervision 19 6.2%

Other disability or impairment 17 5.5%

Child abuse/neglect 15 4.9%

Consanguinity 13 4.2%

Co-sleeping 13 4.2%

Gang/knife crime 6 2.0%

Asthma 6 2.0%

Allergies 5 1.6%

Bullying

40

2.3 Modifiability

Table 26 provides a high-level summary of modifiability. Across the majority of cases, no

modifiable factors were identified. Within 43 of the reviewed cases, modifiable factors were

identified.

Table 26: Modifiability of reviewed cases

Modifiability Number of cases Proportion of

cases

No modifiable factors identified 222 72.3%

Modifiable factors identified 43 14.0%


Not known 7 2.3%

Total 307 100.0%

Table 27 highlights a gender breakdown of the cases grouped by modifiability.

Table 27: Number and proportion of cases grouped by modifiability and gender

Gender

No modifiable factors

identified

Modifiable factors

identified

No data (blank)

No modifiable factors

identified %

Modifiable factors

identified %

No data (blank)

Female 93 16 13 43.5% 37.2% 37.1%

Male 121 27 22 56.5% 62.8% 62.9%

Total 214 43 35 100.0% 100.0% 100.0%

A higher proportion of male than female cases involved modifiable factors (62.8% and 37.2%

respectively). However, male patients comprised a greater proportion of cases overall.

Table 28 provides an age breakdown of the cases grouped by modifiability.

41

Table 28: Number and proportion of cases grouped by modifiability and age category

Age group

No modifiable

factors identified

Modifiable factors

identified

No data (blank)

No modifiable

factors identified %

Modifiable factors

identified %

No data (blank) %

0-27 days 120 10 21 54.3% 23.3% 61.8%

28-364 days 32 16 6 14.5% 37.2% 17.6%

1-4 years 23

42

Tables 30 and 31: Number and proportion of cases grouped by modifiability and

location of death

Location at the time of death No modifiable

factors identified

Modifiable factors

identified

Acute hospital

Acute hospital neonatal unit 65

43

Table 32 provides an overview of the number and proportion of cases grouped by

modifiability and safeguarding issues.

Table 32: Number and proportion of cases grouped by modifiability and safeguarding

issues

Dimension

No modifiable

factors identified

Modifiable factors

identified

No modifiable factors identified

(as a proportion of cases with no

modifiable factors identified)

Modifiable factors identified (as a

proportion of cases with modifiable

factors identified)

Child or family known to social care 13 6 5.9% 14.0%

Child or family known to police 18 11 8.1% 25.6%

Child or family known to both social care and police

44

Appendix 1: Key alongside figure 3: Crude rate of deaths per 1,000 in children aged 1

and under

Number Ward code Ward name Local authority Rate per 1,000

1 E05001043 Broomhill Sheffield 1.1

2 E05001767 Abbey

Derby

4.8

3 E05001768 Allestree 0.8

4 E05001769 Alvaston 2.6

5 E05001770 Arboretum 3.4

6 E05001771 Blagreaves 3.3

7 E05001772 Boulton 1.1

8 E05001773 Chaddesden 1.3

9 E05001774 Chellaston 1.6

10 E05001775 Darley 2.0

11 E05001776 Derwent 0.4

12 E05001777 Littleover 1.9

13 E05001778 Mackworth 2.0

14 E05001779 Mickleover 2.1

15 E05001780 Normanton 3.2

16 E05001781 Oakwood 2.4

17 E05001782 Sinfin 3.4

18 E05001783 Spondon 1.5

19 E05003280 Alfreton

Amber Valley

1.2

20 E05003282 Belper Central 3.8

21 E05003283 Belper East 3.3

22 E05003286 Codnor and Waingroves 7.4

23 E05003290 Heanor and Loscoe 5.8

24 E05003292 Heanor West 1.4

25 E05003293 Ironville and Riddings 5.6

26 E05003295 Langley Mill and Aldercar 3.9

27 E05003297 Ripley and Marehay 3.4

28 E05003299 Somercotes 1.2

29 E05003303 Barlborough

Bolsover

11.5

30 E05003306 Bolsover South 2.8

31 E05003310 Elmton-with-Creswell 1.3

32 E05003311 Pinxton 2.4

33 E05003314 Shirebrook East 5.1

34 E05003315 Shirebrook Langwith 4.6

35 E05003316 Shirebrook North West 3.0

36 E05003317 Shirebrook South East 6.2

37 E05003318 Shirebrook South West 2.9

38 E05003320 South Normanton West 1.3

39 E05003321 Tibshelf 1.7

40 E05003322 Whitwell 2.7

41 E05003324 Brimington North

Chesterfield

5.0

42 E05003326 Brockwell 1.5

43 E05003327 Dunston 1.5

44 E05003333 Lowgates and Woodthorpe 2.1

45 E05003334 Middlecroft and Poolsbrook 1.4

45


46 E05003335 Moor 2.5

47 E05003338 St. Helen's 3.7

48 E05003339 St. Leonard's 1.1

49 E05003347 Calver

Derbyshire Dales

9.2

50 E05003350 Clifton and Bradley 11.6

51 E05003351 Darley Dale 3.6

52 E05003360 Matlock All Saints 4.4

53 E05003366 Wirksworth 2.0

54 E05003369 Cotmanhay

Erewash

1.7

55 E05003370 Derby Road East 1.1

56 E05003371 Derby Road West 3.5

57 E05003372 Draycott 2.3

58 E05003373 Hallam Fields 1.5

59 E05003374 Ilkeston Central 1.6

60 E05003375 Ilkeston North 1.6

61 E05003376 Kirk Hallam 1.2

62 E05003378 Little Hallam 2.3

63 E05003379 Long Eaton Central 1.4

64 E05003380 Nottingham Road 1.0

65 E05003382 Old Park 4.2

66 E05003383 Sandiacre North 1.8

67 E05003387 West Hallam and Dale Abbey 2.3

68 E05003389 Barms

High Peak

11.7

69 E05003392 Buxton Central 8.7

70 E05003395 Corbar 6.1

71 E05003408 Padfield 2.6

72 E05003413 Temple 8.9

73 E05003416 Whitfield 3.5

74 E05003427 Eckington South

North East Derbyshire

2.6

75 E05003429 Grassmoor 1.8

76 E05003432 Killamarsh West 1.9

77 E05003435 Renishaw 10.0

78 E05003436 Ridgeway and Marsh Lane 10.3

79 E05003438 Sutton 3.1

80 E05005511 Appleby North West Leicestershire

4.6

81 E05005523 Measham South 2.0

82 E05006931 Stapenhill East Staffordshire 2.0

83 E05008520 Belper South

Amber Valley

1.4

84 E05008521 Duffield 2.9

85 E05008809 Aston

South Derbyshire

1.8

86 E05008810 Church Gresley 2.2

87 E05008811 Etwall 2.0

88 E05008812 Hatton 10.5

89 E05008813 Hilton 0.8

90 E05008814 Linton 1.9

91 E05008816 Midway 1.0

92 E05008820 Stenson 4.6

93 E05008822 Willington and Findern 2.5

46

Appendix 2: Key alongside figure 5: Crude rate of deaths per 1,000 in children aged 2-

17


1 E05001767 Abbey

Derby

0.31

2 E05001770 Arboretum 0.05

3 E05001771 Blagreaves 0.15

4 E05001773 Chaddesden 0.07

5 E05001777 Littleover 0.24

6 E05001778 Mackworth 0.16

7 E05001780 Normanton 0.12

8 E05001782 Sinfin 0.42

9 E05003281 Alport

Amber Valley

0.55

10 E05003282 Belper Central 0.67

11 E05003284 Belper North 0.30

12 E05003293 Ironville and Riddings 0.20

13 E05003295 Langley Mill and Aldercar 0.19

14 E05003299 Somercotes 0.16

15 E05003309 Clowne South

Bolsover

0.35

16 E05003311 Pinxton 0.30

17 E05003321 Tibshelf 0.41

18 E05003322 Whitwell 0.33

19 E05003329 Hollingwood and Inkersall

Chesterfield

0.13

20 E05003333 Lowgates and Woodthorpe 0.21

21 E05003337 Rother 0.34

22 E05003338 St. Helen's 0.23

23 E05003339 St. Leonard's 0.16

24 E05003351 Darley Dale

Derbyshire Dales

0.21

25 E05003356 Hulland 0.72

26 E05003366 Wirksworth 0.20

27 E05003369 Cotmanhay

Erewash

0.26

28 E05003375 Ilkeston North 0.22

29 E05003376 Kirk Hallam 0.34

30 E05003385 Sawley 0.17

31 E05003388 Wilsthorpe 0.13

32 E05003391 Burbage

High Peak

0.66

33 E05003401 Hayfield 0.54

34 E05003407 Old Glossop 0.21

35 E05003415 Whaley Bridge 0.35

36 E05003417 Ashover

North East Derbyshire

1.66

37 E05003420 Clay Cross North 0.21

38 E05003426 Eckington North 0.38

39 E05003429 Grassmoor 0.27

40 E05003433 North Wingfield Central 0.44

41 E05003440 Unstone 0.64

42 E05005523 Measham South North West

Leicestershire 0.17

43 E05008524 Shipley Park, Horsley and Horsley Woodhouse Amber Valley 0.42

47


44 E05008809 Aston

South Derbyshire

0.33

45 E05008810 Church Gresley 0.11

46 E05008812 Hatton 0.86

47 E05008813 Hilton 0.09

48 E05008816 Midway 0.12

49 E05008817 Newhall and Stanton 0.12

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