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KSCB Child Death

Overview Panel (CDOP)

Annual Report 2015-2016

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Document Name & File Location

K:\FSC KSCB\CDOP\Annual Reports\Reports\2015/16

Document Author Sue Gower & Sarah Craven

Document Owner ©

Kent Safeguarding Children Board © Sessions House County Road, Maidstone. Kent. ME14 1XQ

Email: kscb@kent.gov.uk

Summary of Purpose

The requirement for LSCBs to review all child deaths became a statutory requirement from 1st April 2008. The process is outlined in Working Together to Safeguard Children 2015. In Kent this review process has been the Child Death Overview Panel (CDOP). This document provides an analysis of the deaths that occurred April 2015 - March 2016.

Accessibility This document can be made available in large print, or in electronic format.

There are no copies currently available in other languages

How this document was created

Draft 1 Document created by SG/SC

Draft 2 Review by Chair

Draft 3 Review by CDOP Panel

Draft 4 Ratification by CDOP Panel

Sign off by Business Group

Draft 5 Presented to Board – sign off agreed subject to identified amendments

Draft 6 Sign off by CDOP Chair on behalf of Board

Equalities Impact Assessment

During the preparation of this policy and when considering the roles & responsibilities of all agencies, organisations and staff involved, care has been taken to promote fairness, equality and diversity in the services delivered regardless of disability, ethnic origin, race, gender, age, religious belief or sexual orientation. These issues have been addressed in the policy by the application of an impact assessment checklist.

Circulation Restrictions

None

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Contents Section Page Foreword 4

Chapter 1: Introduction to Kent CDOP 5 Terms of reference 5 Core membership 6 Scope of reviews 7 Definitions of child death categories 7

Chapter 2: Overview of Kent CDOP 10 Child death review process 10 Number of child deaths 11 Meetings held and reviews conducted 11 Modifiable factors 12

Chapter 3: Commentary on the cases reviewed by Kent CDOP 13 Ashford CCG and Canterbury and Coastal CCG 13 South Kent Coast CCG and Thanet CCG 14 Dartford, Gravesham and Swanley CCG & Swale CCG 14 West Kent 14 Expected/Unexpected Child Deaths 15 Age Comparison 16 Categorises of Death 17 Modifiable Factors 17 Chapter 4: Learning points and recommendations 18 Serious Case Reviews 18 Training 18 Key activities and achievements 18 Partner engagement 19 Key challenges 2016-17 19

Appendix A Membership of the CDOP 20 Appendix B Flow Chart – Unexpected death of a Child 21 Appendix C Definitions of categories as required by the

Department for Education and used by CDOP 22

Appendix D Impact Log 23

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Foreword The chairmanship of the Child Death Overview Panel is one of my least enjoyable roles given the human tragedy that lies behind each and every child death in Kent and beyond. However, I like to think that from every tragedy comes an element of learning that helps to make the systems in Kent better for the future. Understanding the causes and circumstances of each and every child death is crucial if we are to learn from these unfortunate events and take effective action where we can prevent future deaths. This report outlines the statutory basis for the Child Death Overview Process and provides the statistics relating to the number of cases the panel assessed and the categorisation of those deaths, age comparisons and more importantly identified modifiable factors relating either to the practice and behaviours of parents, or to the conduct of health staff not following policies and procedures. A key element to the efficient functioning of the panel this year has been the successful implementation of an innovative, secure, multi-agency electronic reporting case management system (eCDOP) the use of which has realised significant efficiencies, resulted in a reduction in the backlog of cases, and facilitated much better communication between partners, generating much interest from other CDOPs around the country. One of the most worrying features of a number of child deaths relates to co-sleeping, excessively high room temperatures for babies less than 6 months, and often associated maternal and parental smoking and/or alcohol consumption. Kent CDOP, in consultation with partners, has launched an advice card with an integral thermometer enabling midwives and health visitors to ensure parents understand the safer sleeping messages. I hope you find this report informative and I would be pleased to hear for you if you have any thoughts, comments or questions on the report. Andrew Scott-Clark Director of Public Health Chair of Kent CDOP

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Chapter 1 Introduction to Kent CDOP

The overall purpose of the child death review process is to conduct a comprehensive, multidisciplinary review of all child deaths, to understand how and why children die and to use the information to develop interventions to improve the health and safety of children in

order to prevent future deaths.1

1.0 Kent Child Death Overview Panel (CDOP) was established on 1 April 2008 in line with Government guidance outlined in ‘Working Together to Safeguard Children’ (HM Government 2006 and updated in 2010 and 2013). The guidance states that all child deaths (excluding stillbirths and planned terminations of pregnancy carried out within the law) up to the age of 18 should be monitored and places the expectation on Local Safeguarding Children Boards (LSCB) that they will:

• Collect and analyse information about each death; • Put in place procedures for ensuring that there is a co-ordinated response

to an unexpected death.

The process of responding to a child death is set out in Chapter 5 of HM Government’s statutory guidance: ‘Working Together to Safeguard Children’ March 20152. It sets out both the method in which a child death should be investigated by the agencies to establish how a child died and the subsequent review process. The review is in addition to any investigation carried out on behalf of the coroner. The Child Death Overview Panel will also examine those deaths where there has been no coronial involvement. The key purpose of reviewing all child deaths is to identify learning and any modifiable factors that could be addressed. The detailed guidance on how a child death should be investigated in Kent can be found in the Unexpected Death of a Child Procedures (2016) at www.kscb.org.uk. They can also be found online in the Kent and Medway Safeguarding Children Procedures: 2.5.3 Child Death Reviews. 1.1. Terms of reference The CDOP’s core functions as set out in its terms of reference include the following, ensuring that:

• local procedures and protocols are developed, implemented and monitored in line with guidance in Chapter 5 of Working Together to Safeguard Children;

• the cause and manner of each death is accurate, consistent and timely reported on;

1 Royal College of Paediatrics and Child Health Guidance on Child Death Review Processes (2008) 2 Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children (March 2015).

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• a minimum dataset of information on all child deaths in Kent is collected and collated;

• lessons to be learnt from the deaths of all children normally resident in Kent are identified and shared across agencies;

• significant risk factors and trends of environmental, social health and

cultural factors in relation to child deaths in Kent are identified with a consideration of how these might be prevented in the future;

• liaison with relevant agencies occurs when preventable factors are

identified;

• the Police or the Coroner are informed of any specific new information that may influence their enquiries;

• the Chair of Kent Safeguarding Children Board (KSCB) is notified of the

need for further enquiries under s 47 of the Children Act 2004 or of the need for a Serious Case Review in the light of new information which may become available;

• there is an appropriate rapid response process by professionals to each

sudden unexpected death and review the reports produced;

• the KSCB is advised on the resources and training required to ensure effective interagency working on child deaths;

• regional and national initiatives in response to prevention of child deaths are

carried out locally. The review process is an opportunity to analyse and evaluate the service delivery and system responses with the potential to improve outcomes for children and families, improve interagency working and identify, prioritise and plan for local needs. 1.2. Core membership Following commencement of the provisions establishing the CDOP on 1st of April 2008, appropriately qualified and suitable persons were selected to become members of the CDOP and invited to participate. A full list of current members can be found at Appendix A.

To ensure a multidisciplinary child death case review process, the selected members belong to a wide variety of local services and have expertise in the fields of public health, paediatrics and child health, neonatology, paediatric pathology, mental health, children’s social care, investigations and child protection, nursing, midwifery, police, education, early help, the ambulance service and other members who can otherwise make a valuable contribution.

Support for the work of the CDOP to ensure it fulfils its statutory requirements is undertaken collaboratively by KSCB and the Kent’s Child Death Review Team.

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1.3. Scope of reviews The Child Death Overview Panel has the responsibility to review the death of all children who are resident within KSCB's geographical area from birth up to the age of 18 years.

1.4 Common Terms relating to Infant Death

Figure 1: Common terms 1.5 Definitions of child death categories

1.5.1 All child deaths The CDOP has the responsibility to review all child deaths up to, but not including, 18 years of age. Kent CDOP’s new electronic case management system (eCDOP) records the deaths of all children and young people under 18 years of age that occur in Kent, including information on cause of death, demographic information, services involved and other relevant factors. This information is reviewed by the CDOP to identify and report on patterns and trends of child mortality. On the basis of this review, the CDOP makes recommendations that are focussed on reducing risk factors associated with all those deaths where modifiable factors may have contributed to the death of the child and which by means of locally or nationally achievable interventions could be modified to reduce the risk of future child deaths. The CDOP also categorises the deaths for annual submission to the Department for Education and produces this annual report.

1.5.2 Expected child deaths An expected death is defined as: a death where the child’s demise is anticipated as a significant possibility 24 hours before the death and plans have been put in place and the cause of death is known. There are no suspicious circumstances to suggest that anything untoward has occurred.3 3 HM Government, Working Together to Safeguard Children (2015)

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Unless the CDOP is sure the death is expected and that the above criteria hold true, the death will be treated as unexpected and the rapid response process will be followed. 1.5.3 Unexpected child deaths An unexpected death is defined as: the death of an infant or child (less than 18 years old) which was not anticipated as a significant possibility for example, 24 hours before the death; or where there was a similarly unexpected collapse or incident leading to or precipitating the events which led to the death.4 The unexpected death category includes both deaths as a result of external factors, such as a traffic accident or a stabbing incident, and deaths as a result of medical causes.

Whenever a child dies unexpectedly, an early response meeting, comprising a group of professionals from different key agencies, comes together for the purpose of assessing all information, enquiring into and evaluating the death. The purpose of the early response meeting is to ensure that the appropriate agencies are engaged and work together to:

• respond without delay to the unexpected death of a child; • ensure support for the bereaved family members, as the death of a child will

always be a traumatic loss – the more so if the death was unexpected; • identify and safeguard any other relevant children; • make immediate enquiries into and evaluate the reasons for and

circumstances of the death, in agreement with the coroner when required; • undertake the types of enquiries that relate to the current responsibilities of

each organisation when a child dies unexpectedly; • collate information in a standard format; • cooperate appropriately post death, maintaining contact at regular intervals

with family members and other professionals who have ongoing responsibilities to the family, to ensure that they are appropriately informed;

• consider media issues and the need to alert and liaise with the appropriate agencies;

• consider bereavement support for any other children, family members or • members of staff who may be affected by the child’s death.

The rapid response process begins at the point of death and ends with the completed report to the CDOP following the late case discussion meeting when the final results of the post mortem and inquest are available and can be shared. 1.5.4 Neonatal A neonatal death is defined as the death of a live born infant within the first 28 days of life. The CDOP reviews all neonatal deaths which have been registered as live with the General Registrar’s Office. However, the CDOP does not consider stillbirths and planned terminations of pregnancy carried out within the law. 1.5.5 Pre-viable neonatal death For the purpose of CDOP review, a pre-viable neonatal death is any infant who was born below 24 weeks gestation with signs of life. 4 HM Government, Working Together to Safeguard Children (2015) 85

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1.5.6 Sudden and Unexpected Death in Infancy (SUDI) A sudden and unexpected death in infancy (SUDI) is an initial classification for infant deaths under 1 year of age, sharing similar characteristics. These deaths are later assigned an official cause of death by a pathologist, such as sudden infant death syndrome (SIDS), respiratory illness or accidental asphyxiation. 1.5.7 Flow Chart A flow chart confirming the Rapid Response process in respect of the unexpected death of a child in Kent can be found at Appendix B.

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Chapter 2 Overview of Kent CDOP 2.0 Child Death Review Process All child deaths must be reported to KSCB by the relevant agency within 24 hours. Agencies who knew the child are then formally asked to provide any known information about the child, their family, their environment and services provided. This information is collated between 4 and 8 weeks after the death, following which it is then reviewed by the Child Death Overview Panel (CDOP) which meets monthly. The CDOP is made up of representatives from health (paediatricians and nurses), police, education, specialist children’s services, Foundation for Study of Infant Deaths, ambulance service and the KSCB, (Appendix A). Other specialists are invited to attend specific meetings when their expertise is required e.g. neonatologist, Police Serious Crash Investigator. 2.1 The Process following the death of a child

Figure 2: Child Death Process

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2.2 Number of child deaths In the 12 month period from the 1st April 2015 to the 31st March 2016, there were 95 child deaths of children and young people, normally resident in Kent. Of these, 80 were within Kent. 47 of these cases were expected and 33 were unexpected. 15 were ‘out of area’ cases, of which 8 were expected and 7 unexpected. In respect of the out of area cases, the Child Death Review team were required to facilitate a proportion of the rapid response processes to assist the out of area Local Safeguarding Children Boards (LSCBs). This year the efficiency of the early response meetings were improved by excellent communication and multi-agency working, ability to provide conference call facilities and the sharing of information due to the implementation of e-CDOP. The most recent released child mortality rate (age 1-17 years) as at March 2016 from the Child and Maternal Health Observatory (Chimat) Child Health Profile is 9.9 in Kent compared to a national average of 12 per 100,000 children. The infant mortality rate is 2.9 per 1000 births compared to a national average of 4.0. Compared to last year, both rates can be seen to be lower in Kent. The child mortality rate is identified as being not significantly different, while the infant mortality rate is identified as significantly better than England’s average. 2.3 Number of meetings held and reviews conducted Kent CDOP has reviewed 96 cases and completed 89 cases during the period from the 1st April 2015 to 31st March 2016. The originating time period for the cases in question is as follows: 2012-13 2013-14 2014-15 2015-16

6 3 36 44 Table 1: Cases presented by year of death

The CDOP carries out an assessment against national templates when conducting

a review; this includes a consideration of the following matters: • categorisation of death; • modifiable factors of death; • issues; • learning points; • recommendations; • follow up plans for the family (where relevant); and • whether the case warrants referral for further investigation.

2.4 Categorisation of death The CDOP are required to categorise every death using the definitions below. These are fully detailed at Appendix C.

1. Deliberately inflicted injury, abuse or neglect 2. Suicide or deliberate self-inflicted harm 3. Trauma and other external factors 4. Malignancy 5. Acute medical or surgical condition 6. Chronic medical condition 7. Chromosomal, genetic and congenital anomalies 8. Perinatal/neonatal event 9. Infection 10. Sudden unexpected, unexplained death

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2.5 Modifiable Factors The CDOP is required to categorise the preventability of a death by considering whether modifiable factors may have contributed to the death of the child and which by means of locally or nationally achievable interventions, could be modified to reduce the risk of future child deaths. These are discussed and recommendations made in order to raise awareness of any issues and to prevent future deaths. Gaps in service provision both prior to the death and afterwards, such as bereavement support are also identified and any public health issues considered. 2.6 Themes and Learning The CDOP reports local and national themes and learning issues annually to the KSCB. In addition, any findings and recommendations are shared with partners via the KSCB Update, KSCB Trainer Bulletin and partner publications. Local child death trends are also shared with the national CDOP network. 2.7 CDOP support and administration The KSCB and CDR team share the responsibility for managing the local child death processes collaboratively and effectively. Kent’s newly developed electronic CDOP case management system is now routinely used by both teams and has realised significant efficiencies. 2.8 Commentary on CDOP meetings CDOP meetings are scheduled on a monthly basis and are themed to consider a number of deaths of a similar nature i.e. neonatal, SUDI. Attendance by Police, Education and Early Help is not required for neonatal deaths. Equally, the Lullaby Trust is only represented at SUDI meetings.

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Chapter 3

Commentary on Child Deaths in Kent 2015-16 3.0 Child Deaths across Kent Clinical Commissioning Groups (CCG) areas

Figure 3: Child deaths across CCG areas The total number of child deaths registered in Kent in 2015-16 was 80 (0.23 per 1000 population aged 0-18), with 38 of these being neo-natal deaths (2.20 per 1000 births). Geographically, West Kent CCG had the most cases (22) and Swale CCG the fewest (5), although taking into account the relative population sizes, this accounts for 0.20 per 1000 population 0-18 in West Kent, and 0.19 in Swale. Although the total number of deaths has seen an increase of 17 cases over the year, the increase in number of deaths overall has been partly down to a doubling of Out of Area cases, 8 in 2014/15 to 15 in 2015/16. 3.0.1 Ashford CCG and Canterbury and Coastal CCG During 2015/16 the total number of deaths of children resident in Canterbury and Coastal CCG was 9 (0.20 per 1000 population aged 0-18), in Ashford it was 7 (0.23 per 1000 population 0-18), with a total of 10 cases across Ashford and Canterbury being neonatal (3.03 per 1000 births). Two cases were deaths from life limiting conditions. The ratio of expected to unexpected death was 10:6.

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Two unexpected cases required section 47 investigations due to risks from extended family or concerns relating to siblings. Both cases have not yet been reviewed by CDOP however it is likely that the post mortem results will identify the cause of death as sudden unexplained death in infancy (SUDI). Taking into consideration the local increase in SUDI cases, the Specialist Nurse identified a common theme and recommended a learning outcome that all professionals, including GPs, re-enforce safer sleeping messages especially when a baby is unsettled and irritable due to mild cold symptoms. 3.0.2 South Kent Coast CCG and Thanet CCG During 2015/16, South Kent Coast has had 13 cases (0.31 per 1000 population 0-18), with 8 unexpected and Thanet have had 10 (0.32 per 1000 population 0-18), with 5 unexpected. Of the unexpected cases one involved a term baby being unsuccessfully resuscitated at birth, and a Root Cause Analysis was undertaken. Another case resulted in a Section 47 investigation which proceeded to a Serious Case Review (SCR). This case has not as yet been reviewed at CDOP; outcomes will be published once it has been reviewed. One unexpected death involved a Looked After Child who was placed by an out of area authority in a residential care home. The London CDOP will complete the review of this death. There was an unexpected death of a baby who was undergoing assessment by Specialist Children Services due to poor housing. Initial findings indicate that this is a sudden unexplained death in infancy; however the CDR team is awaiting the full post mortem results. One case is undergoing an RCA from the acute provider due to an unexpected collapse during intubation and the service is awaiting the report. The Designated Doctor ensured that immediate lessons learnt were implemented and assurance was gained that South Thames Retrieval Team guidance would be adhered to whilst the investigation was being conducted. Two unexpected cases required section 47 investigations due to identified risk factors. Both cases have not as yet been reviewed by CDOP once they are reviewed a fuller explanation will be given and any learning of other documents produced readers will be signposted to those for research/review purposes. 3.0.3 Dartford, Gravesham and Swanley CCG, and Swale CCG During 2015/16 the total number of child deaths in Dartford, Gravesham and Swanley CCG was 14 (0.23 per 1000 population 0-18), and in Swale CCG there were 5 (0.19 per 1000 population 0-18). Of these, a total of 12 were neonatal deaths, 8 in DGS CCG (2.35 per 1000 births), and 4 in Swale (2.79 per 1000 births). The unexpected deaths did not raise any concerns. One case was reported as a Serious Incident. However, this was downgraded once the post mortem was received as a Sudden Unexplained Death in Infancy. From this case, a recommendation was raised to ensure all professionals - including GPs, re-enforce safe sleeping messages especially when a baby is unsettled and irritable due to mild cold symptoms. 3.0.4 West Kent CCG During 2015/16, West Kent CCG has had 22 cases (0.20 per 1000 population 0-18), with 10 unexpected, 6 expected and 6 neonatal deaths (1.12 per 1000 births).

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One unexpected case of a child dying from an overwhelming sepsis was led by health. Two cases resulted in a Section 47 investigation. The first, as the family was open as Child in Need and there were safeguarding concerns around the home environment. These investigations were subsequently closed as there were no suspicious circumstances. The other case was also downgraded quickly, and highlighted excellent multi agency working practices. This has since been used as a case example to modify the KSCB child death procedures. One case occurred overseas and the Designated Doctor and Specialist Nurse worked closely with the police to obtain accurate details surrounding the circumstances of the death. The GP surgery was pivotal in supporting the child death review team to arrange a joint visit by the police and the Designated Doctor. The unexpected birth and subsequent death of a neonatal baby required the team to work across border with the Designated Doctor in Medway. This case was subsequently managed by Kent CDOP panel and underwent successful joint working with both Medway and SECAmbs Trusts. One of the unexpected cases, led by health, raised media interest due to the tragic circumstances that arose but no safeguarding concerns or suspicious circumstances were raised by any multi-agency partner. Learning was generated following the death of a child with a life limiting condition who died unexpectedly. The Specialist Nurse arranged training for the Hospice at home team to ensure that staff members have a clear understanding of the unexpected child death procedures to fully inform parents as part of their package of care. 3.1 Expected and Unexpected deaths Looking at the statistics for expected vs unexpected cases, in 2015/16 we have seen a drop in unexpected cases, from 51% to 41% of cases in this report period.

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Expected v Unexpected

Expected

Unexpected

Figure 4: Expected v unexpected In addition to the 80 cases from 2015/16, and expected/ unexpected split, shown in the diagram above, an additional 9 cases were reviewed and closed by CDOP during the 2015/16 period. These were cases where death occurred in a previous time period (see table 1, page 12). This resulted in a higher percentage of unexpected deaths taken to CDOP in 2015/ 2016, which are detailed below.

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3.1.1 Expected child deaths taken to CDOP in 2015/ 16 Thirty-five (39%) of the eighty-nine cases reviewed by CDOP in the period of this report, which as previously mentioned included previous years cases, were defined as expected child deaths. 3.1.2 Unexpected child deaths taken to CDOP in 2015/16 Fifty-four (61%) of the eighty-nine cases reviewed by the CDOP in the period of this report, which as previously mentioned included previous years cases, were defined as unexpected deaths. 3.1.3 Age Comparison The age comparison of the child deaths in 2015/16 appears below.

Age Number 0-28 days 41 29 days – 1 year 18 1-4 years 9 4-11 years 6 11-18 years 6 Table 2: Age comparison As can be seen, the neonatal and infants up to one year of age represent the highest number of child deaths, accounting for 59% if cases in 2015/16. 3.1.4 When comparing cases from this year with those reviewed last year, there has been a significant increase in deaths of babies up to 28 days old, from 23 last year to 41 in this reporting period. The number of deaths of 1-4 year olds have increased from 7 to 9 cases, whilst the deaths of 4-18 year olds have decreased from 21 l;ast year to 12 this year, with the cases of 11-18 year having fallen by over 50%, suggesting that the preventative measures of previous years are effective.

Figure 5: Age comparison 3.2 Neonatal deaths

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The largest group of child deaths was in the neonatal age range (41 cases). This shows an increase in the number of neonatal cases in Kent, and was discussed at CDOP. The Neonatal Consultant representative advised the panel that Kent remains below the national average for neonatal deaths and that this data will need to be reviewed over a longer time span to indicate a sustained increase. The current information is difficult to analyse as there seems to be no emerging trends. 3.3 SUDI Sudden Unexpected Death in Infancy accounted for 9 cases this year compared to 4 cases last year. In all cases safe sleeping advice was given by midwifery and/ or health visiting teams. Predominantly, factors continued to identify parental smoking and home conditions as contributory risk. Other factors included drug and alcohol misuse, low birth weight, recent snuffles, overheating and room temperatures. Enormous progress has been made with the safer sleeping campaign and a launch of the finalised room thermometer card, which encompasses the Lullaby Trust guidance on Do’s and Don’ts for safer sleeping, which coincided with Safer Sleeping Week on 14th March 2016. All partner agencies were invited to the launch to raise awareness and obtain feedback from the thermometer card. This successful event ensured multi agency input was gained for the finalised thermometer card, ready for it launch in the autumn 2016. 3.4 Adolescent deaths The numbers of adolescent deaths has decreased this year from 13 in 2014/15 to 6 cases in 2015/16. In 2014/15, half of the cases were due to life limiting conditions or natural causes, with suicide, homicide and death relating to drugs misuse accounting for the remaining cases. In 2015/16, 50% of the cases were due to life limiting conditions, or from an exacerbation of a known medical condition; 2 from road traffic incidents; and the remaining case from suicide. 3.5 Categories of Death The cause of death comparison was also looked at within Kent, see table below, and compared to the previous year. This has shown a rise in neonatal deaths and undetermined /SUDI cases; a decrease of 50% in deaths by natural causes and a drop in the unclassified (no post mortem) deaths. All other causes remained relatively constant, and there were no cases of apparent homicide or due to substance misuse in 2015/ 16.

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Figure 6: Categories of death 3.6 Modifiable factors The CDOP consider whether there are any modifiable factors which, if addressed, may prevent similar deaths in the future. It also seeks to identify whether any lessons can be learned from the death and whether there are any patterns/similar deaths in the area. 3.7 The CDOP identified modifiable factors in ten (11%) of the eighty-nine cases that were reviewed, lower than the national average of 24%. The Kent CDOP is confident that all cases are reviewed comprehensively, and that professional challenge remains a central part of the review process. The modifiable factors include:

• Co-sleeping • Room temperature • Alcohol consumption by parents • Smoking in pregnancy • Smoking in the house • Hospital policy and procedure not followed fully, and inadequately

documented to include reasoning for actions

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Chapter 4 Learning points and recommendations 4.0 Wherever possible the CDOP seeks to improve the child death review process and indirectly impact upon the safety and wellbeing of children and young people in the area. The main reason for focussing on the child death review process itself is that its quality directly influences the extent of learning derived. The identification of learning in turn, when cascaded to partners, plays a significant role in informing and improving the safety, wellbeing and services to children and young people in Kent 4.1 Learning Points A number of learning points have been identified during the period of this report and these appear at Appendix D – Impact Log – which details issues identified by Kent CDOP, action taken, and the impact achieved. National issues and trends are regularly monitored and discussed within CDOP. Members then disseminate relevant information with their teams. KSCB incorporate this learning within its training as appropriate.

4.2. Serious Case Reviews (SCRs) LSCB’s are required to undertake SCRs when a child dies and neglect or abuse is known or suspected. The requirements for SCRs are set out in Chapter 7 of ‘Working Together to Safeguard Children 2015’. The KSCB Case Review Panel determine whether a Serious Case Review should be commissioned, either as part of the statutory requirement or where it is felt that the resulting information will inform practice. Copies of all Executive Summaries arising from Serious Case Reviews and management reviews undertaken by the Kent Safeguarding Children Board are published on the Board’s website: www.kscb.org.uk. On the period 2015-16 two cases were identified as meeting the criteria for serious case review. 4.3. Training During 2015-16, a total of 100 practitioners attended four training sessions relating to the Child Death Review Process. In addition, regular training continues in partnership with Kent Police as part of SCAIDP. 4.4 Key activities and achievements Key activities for the Child Death overview panel include:

• Reducing the backlog of cases from previous years. The backlog has now been cleared and Kent CDOP cases are now in-year.

• A campaign to raise awareness of frontline practitioners of the “safer sleeping” message, inclusive of safer sleeping practices, to reduce the number of sudden infant deaths in Kent. Two successful multi-agency consultation events were held to engage partners and agree a consistent message in respect of the issues. (Appendix E) An innovative product is being developed that will be distributed to all expectant mothers in their last trimester.

• Improved communication with the Case Review Group.

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• Implementation of a new web-based electronic system (eCDOP) which enables secure and easy access for all partners to notify details of a child death. This has realised the effective and efficient management of the child death overview process via a secure online process by KSCB and CDR teams. A sample report for the period in question appears at Appendix D.

Picture1: eCDOP

4.5 Partner engagement Multi-agency partner engagement within Kent CDOP continues to improve and membership has recently been extended to include representation from Kent’s Early Help and Preventative Service. Good collaboration is evident: “A healthy pro-active group. I have found like-minded enthusiastic professionals who truly are trying to prevent child death”. (Kent Police) 4.6 Key challenges 2016-17 The key challenges for the Child Death overview panel include:

• Increasing the use of eCDOP with wider partners, including the coronial service

• Timetable of meetings scheduled to progress new arrangements • Ensuring the child death overview policies are fit for purpose and

implemented effectively, particularly where another external authority has some local involvement

• Implement new process to routinely follow up and report on out of area child deaths and the outcome of other LA’s CDOP panels.

• Review of functions in line with outcomes of the national review of the CDOP process.

• National CDOP report anticipated by autumn in respect of national changes. This will be considered and actions identified.

• Enhanced monitoring and tracking of cases that are referred to the Case Review Group as a result of CDOP panel concerns.

• Closer links with Case Review Group. • Engagement and roll out across partners the lessons from SCRs • Getting the message out on safer sleeping as it is still occurring despite

repeated advice/campaigns. • Improved Coroner engagement • Finalise and roll out Safer Sleeping product

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APPENDIX A Membership of CDOP

Name Agency Title Andrew Scott-Clark (Chair)

KCC Public Health Director of Public Health

Charles Unter (Vice Chair) Kala Pathy

Maidstone & Tunbridge Wells NHS Trust

Consultant Paediatricians

Selwyn D’Costa Dartford & Gravesham NHS Trust

Consultant Paediatrician

El-Hussein Rfidah Amitha Sumathipala Ameen Siddiqui

East Kent Hospital NHS Trust Consultant Paediatricians

El-Hussein Rfidah East Kent Hospital University Foundation NHS Trust

Consultant Paediatricians

Amit Gupta NHS Consultant Neonatologist

Susie Harper Kent Police Detective Chief Inspector Lee-Anne Farach Paul Brightwell

Head of Practice Improvement Specialist Children’s Services

Tom Stevenson Head of Safeguarding Quality Assurance

Dawn Morris Quality Assurance Manager: North West Kent Child Protection Chairs Service

Claire Ray CFE/ Education Services Area Education Safeguarding Adviser (West Kent)

Sue Gower Kent Safeguarding Children Board

KSCB Programme Development Officer/CDOP Co-ordinator

Sue Gibbons Kent Community Health NHS Trust

Specialist Nurse Child Death

Conor Walsh SEC Ambulance Service Safeguarding Support Officer

Nick Fenton Early Help & Preventative Services 0-25 Head of Service

Celina Grant Ashford and Canterbury CCGs Designated Nurse Safeguarding Children

Wendy Everitt NHS Kent & Medway Designated Nurse Safeguarding Children

Judith Howard Lullaby Trust Regional Development Officer Liz Luck KSCB Administrator

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APPENDIX C Department for Education CDOP Categories

1. Deliberately inflicted injury, abuse or neglect This includes suffocation, shaking injury, knifing, shooting, poisoning & other means of probable or definite homicide; also deaths from war, terrorism or other mass violence; includes severe neglect leading to death.

2. Suicide or deliberate self-inflicted harm This includes hanging, shooting, self-poisoning with paracetamol, death by self-asphyxia, from solvent inhalation, alcohol or drug abuse, or other form of self-harm. It will usually apply to adolescents rather than younger children.

3. Trauma and other external factors This includes isolated head injury, other or multiple trauma, burn injury, drowning, unintentional self-poisoning in pre-school children, anaphylaxis & other extrinsic factors. Excludes Deliberately inflected injury, abuse or neglect. (Category 1).

4. Malignancy Solid tumours, leukaemias & lymphomas, and malignant proliferative conditions such as histiocytosis, even if the final event leading to death was infection, haemorrhage etc.

5. Acute medical or surgical condition For example, Kawasaki disease, acute nephritis, intestinal volvulus, diabetic ketoacidosis, acute asthma, intussusception, appendicitis; sudden unexpected deaths with epilepsy.

6. Chronic medical condition For example, Crohn’s disease, liver disease, immune deficiencies, even if the final event leading to death was infection, haemorrhage etc. Includes cerebral palsy with clear post-perinatal cause.

7. Chromosomal, genetic and congenital anomalies Trisomies, other chromosomal disorders, single gene defects, neurodegenerative disease, cystic fibrosis, and other congenital anomalies including cardiac.

8. Perinatal/neonatal event Death ultimately related to perinatal events, egsequelae of prematurity, antepartum and intrapartum anoxia, bronchopulmonary dysplasia, post-haemorrhagic hydrocephalus, irrespective of age at death. It includes cerebral palsy without evidence of cause, and includes congenital or early-onset bacterial infection (onset in the first postnatal week).

9. Infection Any primary infection (i.e., not a complication of one of the above categories), arising after the first postnatal week, or after discharge of a preterm baby. This would include septicaemia, pneumonia, meningitis, HIV infection etc.

10. Sudden unexpected, unexplained death Where the pathological diagnosis is either ‘SIDS’ or ‘unascertained’, at any age. Excludes Sudden Unexpected Death in Epilepsy (category 5).

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APPENDIX D Impact log: 2015/16

Issue Action Anticipated Impact Incidences of deceased children under 18 not always being co-examined with Police as per CDOP procedures.

Confirmation received from Medical Directors in respect of their compliance with existing CDOP procedures for 16-18 year olds.

Consistency of message across health settings that aims to ensure full involvement of the Police at the earliest opportunity.

Apparent lack of awareness of factors relating to child asthma deaths

Article relating to asthma deaths authored by CDOP Chair and Deputy Chair published in the Local Medical Committee Newsletter

Multi-agency partners have increased understanding of contributory factors to asthma deaths

Examples of core multiagency partners not being routinely invited to Strategy meetings after the death of a child

Direct communication with relevant agencies of the need for all multi-agency partners to be invited to both Early Response or Strategy meetings

• Increased awareness of the local CDOP process

• Optimum information sharing Mis-communication between ambulance service and hospital resulting in lack of a specialist team to receive child

Assurances sought – and received - from those concerned in respect of future situations

• Reduced risk of repeat event • Improved communication

processes Inconsistent information sharing with Case Review (CR) Group

Member of CDOP Panel now a member of CR Group

Enhanced information sharing and understanding of decision making process

Concern at the number of Sudden Infant Deaths reported in Kent every year

Multi-agency meeting to agree standardisation of safer sleeping message across Kent and development of an effective product to help parents/carers monitor the temperature of the room in which their baby is sleeping – day or night.

• Consistent safer sleeping message across Kent to inform practitioner discussions with parents.

• Health Visiting teams proactively discussing safer sleeping with parents antenatally

Original hospital notes being removed out of hours by external agency

Relevant agency contacted and assurances given that such bad practice will be stopped. Revised information developed confirming the process by which information should be shared between relevant hours

Increased awareness of best practice communication and information security.

Failure of sonographer to identify a foetal abnormality following an ultrasound scan.

Assurances sought and provided that all sonographers in the relevant setting receive training to identify foetal abnormalities. Refresher

Improved pre-natal practice to identify foetal abnormalities at the earliest opportunity

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training provided. Concern about lack of response by an out of area school to a child who disclosed self-harm/suicidal thoughts

KSCB self-harm literature highlighted to all staff working with children placed outside Kent with confirmation of local early help processes and how these can be accessed.

Proactive response and support for children who disclose self-harm/suicidal thoughts

Absence of a process to deal with deceased Unaccompanied Asylum Seeker with no identification but who appears to be under 18.

Agreement in principle secured that such deaths will be dealt with in accordance with Kent CDOP procedures until formal confirmation of age received. KSCB UASC training put in place

Consistency of approach and clear procedures for all agencies.

Lack of Early Help representation at early response meetings (ERMs)

New process agreed - Early Help are now routinely notified of the death of a child and attend the ERM if known to the service. If not, SCS will share any relevant information

Earlier and more robust information sharing and support for family

Inefficient administration of CDOP processes and delays in receipt of partner information

Development of a new electronic case management system that electronically enables Kent’s CDOP process - eCDOP

Accurate and real time information securely received, stored and shared. Significant efficiencies realised.

Lack of partner awareness about eCDOP Communications exercise undertaken – presentations delivered to all Hospitals and GPs. CDOP training course developed and a regular part of KSCB’s offer.

• Consistency of message • Key stakeholders fully informed

about new system, rationale and benefits

Out of area traffic death where the police present had neither a history of the child nor awareness of CDOP procedures.

Assurances sought and received from relevant local authority confirming that CDOP training would be provided to all staff and that it would be consistent with that received by Kent Police.

Consistency of approach Efficient notification of child deaths that occur outside Kent

The need for timely feedback in respect of cases referred to the Case Review panel

Template developed to formally notify CR Group of cases from CDOP and updates from CR group to be standing item on CDOP agenda. Issue also highlighted to Business Group

Clarity of understanding in respect of decisions made by the CR Group in respect of cases notified to them by CDOP.

Re-routing of ambulance due to hospital declining to accept paediatric patient

Assurances sought and received from Medical Director, Paediatric Consultant and A&E Consultant at hospital clarifying acceptance criteria for paediatric patients requiring resuscitation

• Improved clarity of process for partners

• Optimum treatment pathway in place

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Number of deaths involving the wearing of headphones on roads/railway crossing

Improvements made to visibility and auditable warning system at unmanned rail crossings Warnings about use of headphone on roads and when using level crossings placed in Schools e-Bulletin and cascaded to partners The need for awareness raising of the danger of the use of ear/headphones by young people when crossing roads/railway lines communicated to KSCB trainers

• Enhanced awareness of the risks associated with wearing headphones when crossing roads/railways

• Reduction in number of associated deaths

• Consistency of message

Parents unwilling to accept advice from midwife Medical Directors of each trust contacted and advised that in such cases a Paediatrician should speak directly to parents.

Ability to escalate concerns at earliest opportunity if specialist advice is ignored.

Inability to progress case to Panel due to delay in receipt of information from Coroner

Improved processes put in place – Coroners now share information on eCDOP.

Improved information sharing Timely processing of cases to Panel

Need identified for formal information sharing between CDOP and those responsible for children in care in Kent to ensure full understanding of issues – particularly when their placing authority is outside Kent.

Contact made with the relevant AD and assurances provided in this respect.

• Enhanced information sharing and understanding of issues

• Increased awareness of issues by the Corporate Parenting Board.

Confusion in respect of criteria for holding an ERM/Strategy meeting

Procedures revised. New ‘Immediate response’ introduced as part of local process. Explicit guidance developed in respect of the ERM and Strategy meetings.

Increased understanding of local CDOP process by stakeholders Effective meetings with appropriate Chairmanship

Non-attendance of consultant at birth of a baby of 27 weeks’ gestation

Assurances sought and received from hospital concerned that a consultant will attend any baby delivered below 27 weeks gestation

Expert overview of delivery and appropriate intervention if required.

Lack of multi-agency awareness of local child death processes

Multi-agency seminar held to highlight issues, share learning and address issues Regular training now in place

• Consistency of understanding • Increased awareness • Identification of issues

Water-related death Enhanced publicity provided by schools regarding water awareness

Awareness raising Consistency of message

National issues and trends i.e. button batteries Training enhanced with relevant information Information included in KSCB Trainer Bulletin ‘National overview’ is now a standing item at each CDOP meeting

Enhanced awareness of current risks and issues.