Agenda item

Rob Howard (Consultant in Public Health, Leicester City Council) and Dr Suzanna Armitage (Consultant Community Paediatrician and Designated Doctor for Child Death, Leicestershire Partnership Trust) will outline the work of the Child Death Overview Panel (CDOP) and present the findings of the CDOP annual report.

Rob Howard (Public Health Consultant, Leicester City Council), and Dr Suzi Armitage (LLR Designated Doctor for Child Deaths), gave a presentation on the annual report for 2021/22 for the LLR Child Death Overview Panel (CDOP). It was noted that:

·         CDOP was a statutory duty to review the deaths of all children in LLR.

·         CDOP produced an annual report, a new report would be released before the end of the calendar year.

·         Death notifications were more closely aligned with the actual date of death. The reviews typically took place months and sometimes years later after a long process of other investigations for example Coroner’s, Serious Incident, and Police investigations.

·         The aim of the review was to consider which factors contributed to the vulnerability or death of the child and which were modifiable by national or local means.

·         There had been a significant increase in the number of notifications in 2021/22 compared to previous years. This could have been due to delayed deaths from those in lockdown who weren’t exposed to infections they were vulnerable to until after. A small increase had also come from now recording deaths in all those who showed signs of life in any the gestation period.

·         Infant mortality in Leicester was higher than in the rest of LLR and England. Infant mortality was seen as a strong general indicator of the health of the community and was linked strongly to poverty.

·         Due to the time to complete reviews, some reviews included in this report were from as far back as 2017/18. In 2021/22 71 cases had been reviewed.

·         Underlying causes of death were broadly very similar to the national picture, with the largest category being neonatal events.

·         The majority of child deaths were within the first year of life.  

·         When the narrative of a death was being considered, factors that may have contributed to the death were considered and those which were potentially modifiable were determined. Modifiable factors had been identified om 37% of cases. There was found to be a clear link between risk of death and deprivation across almost all categories. 

·         It had been found that suicide cases were not correlated to any demographic group, 62% has suffered a major personal loss, over a third had never been in contact with mental health services, 16% had a confirmed neurodevelopmental condition, and almost a quarter had experienced bullying. Suicide deaths were reviewed every 2 years.

·         Alongside CDOP there was another process for reviewing deaths of those over 4 years old with learning disabilities (LEDER). Of 16 of these cases modifiable factors had been found in 3. The key learning area from this work was that communication between different organisations and processes was key.

·         A function of CDOP was to collate the learning processes from each body for each death together. Learning had been identified across al categories.

·         Key learning points were on the need for more integrated IT systems, need for early recognition of vulnerability, and better safer sleep conversations.

·         Recommendations from the report included a digital solutions to improve communication, a refreshed strategy on infant mortality, and working with stakeholders to produce a thematic report on suicide and self-harm.

Members of the Board commented that it would be helpful to be able to determine how the work ongoing in this area was having an impact on data.

In response to a question from the Chair, it was noted that the messages from this work on topics such as safer sleep had not changed in 7 years of work, however increased evidence and understanding had led to a better understanding of vulnerability and where to target conversations. Working practices had been proving throughout the period of using these factors. It was also noted that work on smoking cessation was available to partner organisations.

RESOLVED:

That the Board thanks Officers for the report.