Agenda item

The Director of Public Health, Leicester City Council and Dr Suzi Armitage, LLR Designated Doctor for Child Deaths, Leicestershire Partnership Trust will outline the work of the Child Death Overview Panel (CDOP) and present the findings of the CDOP annual report to the Commission.

Due to the similarity in the items, the LLR Child Death Overview Panel Annual Report and the report on Reducing Infant Mortality were taken together.

The Director of Public Health, Leicester City Council and the LLR Designated Doctor for Child Deaths, Leicestershire Partnership Trust outlined the work of the Child Death Overview Panel (CDOP) and presented the findings of the CDOP annual report to the Commission.

Slides were presented as attached with the agenda pack.  Additional key points to note were as follows:

·       This was a very challenging area, but the team supported families.

·       A report had been produced to collate the narratives and to prevent future deaths.

·       The data was based on child deaths notified to the service.

·       A key issue was support for the family.  The team acted as a key worker for families.  Families were supported to participate in the review process and feedback.

·       Once a child dies, there was a period of decision making.  Following this there was an investigation and information gathering.  This could take the form of anything form a criminal investigation to a post-mortem.  Once this was concluded, staff were brought in for review and analysis was begun to look at what may have contributed to the death in order to capture learning.  This was reviewed at a panel for final independent scrutiny.

·       All data went into the national database.

·       Infant mortality in Leicester was higher than in England and in the county of Leicestershire.  Work was being undertaken to understand what was driving this.

·       In terms of wider context, it was key to note that deprivation was strongly associated with child mortality.  Babies in the most deprived fifth percentile of the population had twice the deathrate of the least deprived.

·       The first dataset reviewed were the notifications as there was a statutory duty to notify of a death.  There had been 92 notifications in total, a quarter of which required a joint-agency response.

·       Over half of notifications were death after birth, but while the baby was still in hospital.  Many of these were pre-viable gestation.

·       20% died at home.  Some of these had died suddenly, but others had planned end-of-life care.

·       Prolonged information gathering could cause reviews to take a long time to complete.  The majority of cases were complete within 12-18 months.

·       Nationally, most deaths were perinatal or neonatal, the second biggest category were chromosome or congenital anomalies and the third were malignancy or unexplained issues.

·       Contributory factors were factors that could have contributed to the death, often in terms of family, social and environmental factors, and social services received.  A modifiable factor was a factor that, if it had been different, might have led to a different outcome.

·       Early warning scores could help to catch risks early but did not always work.

·       When safety mechanisms needed to interact but worked in different systems, this could be a risk.

·       Information gathering was carried out, and interpretations were made before a decision was made.  Therefore, it was necessary to have access to people with the expertise to analyse and interpret.

·       The quality of referrals could make a difference.

·       A clear evidence base policy and guidance were need.  Information sharing to identify the emergence of risks could be useful.

·       A model put decision making into context of interpersonal interaction.  The quality of interaction could affect what was done with decisions.

·       Wider organisational and system processes were present.  This risk assessment and interaction occurred in this context.  It was necessary to have available and effective resources to tackle risks.

·       It was noted where things had gone well.  This was captured through a free-text box and put into a word-cloud as set out on the slide.

·       In terms of thematic learning, every year, cases were looked at to consider themes and recommendations.

·       Learning was done at a national level and a commissioner level and shared with LLR.

The Acting Consultant in Public Health submits a report to update the Commission on the Infant Mortality Rate in Leicester.

Slides were presented as attached with the agenda pack.  Additional key points to note were as follows:

·       Infant mortality referred to death in the first year of life.  It was a complex issue and not all of the answers were available.  However, a lot of good work was being undertaken.

·       Leicester had the second-highest rate of infant mortality in England.

·       Infant mortality rates were higher for BAME babies.

·       Due to the high rate, it was necessary to understand what was happening in the city and to make changes.

·       Key stakeholders were being worked with and asked why they thought the rate was so high, what could be done differently and what was going well.  This feedback was analysed and taken to a conference with other stakeholders where themes were presented in a logic model to look at how to get to solutions.  Comments were analysed to come up with an account plan and delivery.  There was a system-wide steering group.  Actions were complex and system wide.

·       The action plan was in the first draft.  Possible solutions included a multi-disciplinary approach, better equipping people to have a healthy pregnancy

·       Care navigation included more support for fathers, streamlining the process, the delivery of the bumps-to-babies antenatal sessions, and advice on breast feeding.

·       The charity Baby Basics were worked with to ensure that there was no waiting list for safe sleep spaces (moses baskets and cots) for babies.

·       There was lots of work to be done, it was challenging, but the service were committed.

In response to member questions and comments, the following was noted:

·       Support was expressed for taking the reports together. Concern was raised about the high proportion of deaths in the neonatal period and the correlation with low birth weight and higher mortality rates among Black mothers and babies. It was queried what measures were currently in place, including whether care passports were effective in preventing information loss. It was outlined that many neonatal deaths related to extremely premature births, with very low survival rates at earlier gestations, and that robust pathways were in place to optimise care and outcomes. Care passports aimed to improve communication and reduce the need for families to repeat their experiences.

·       It was highlighted that disparities in outcomes for Black mothers and babies persisted even when deprivation was accounted for. It was noted that while no single consistent theme had been identified, cases were reviewed individually, with learning logged and action taken where required.

·       It was noted that wider work was being undertaken across the system to address inequalities linked to poverty, housing and ethnicity, including consideration of the experiences of looked after children and care experienced parents. It was outlined that data relating to care experience was collected and considered, although local numbers were small and national data sharing remained complex.

·       The strong link between deprivation and infant mortality was emphasised, with significantly higher death rates in the most deprived areas. Concern was raised about the impact of wider societal factors, including housing conditions, reduced public health resources and increasing inequalities. It was suggested that both local and national action was required, including raising concerns with government and national bodies

·       Many of the recommendations were longstanding, raising questions about whether key messages were effectively reaching communities. It was queried whether outcomes differed for new arrivals and what data was available to understand this. It was explained that data collection was being strengthened, and that safe sleeping remained a key area of focus. It was also noted that changing parenting contexts, including reduced family support and the impact of COVID 19, had influenced risk factors.

·       It was acknowledged that consistent public health messaging remained important, with a need to consider how messages could be delivered differently to improve impact.

·       Emerging trends were highlighted, including a small number of cases linked to IVF treatment abroad, where higher risk practices may be used. It was noted that increasing awareness of these risks would be important.

·       Strong concern was expressed regarding Leicester having one of the highest infant mortality rates nationally. Pressures on maternity services, including estate capacity and increasing demand, were highlighted, alongside challenges in accessing local perinatal services. It was suggested that more targeted action was needed in areas of highest deprivation. It was queried how system partners, including the ICB, would support addressing these issues.

·       System wide resource pressures were acknowledged, alongside the importance of early intervention and wider social determinants of health. It was noted that outcomes would likely be worse without existing services and education.

·       It was queried whether there was national best practice that Leicester could adopt, particularly in relation to housing, indoor air quality and smoke free environments. It was outlined that work was evidence based and tailored to Leicester’s needs, with links to housing and enforcement of standards such as damp and mould. Opportunities to strengthen partnerships with housing providers were identified.

·       The impact of smoking and indoor air quality was discussed, including the risks to infants returning to home environments following hospital care. It was noted that further work with landlords and tenants could support smoke free homes.

·       The role of vaping was discussed, including its use as a smoking cessation tool and concerns regarding uptake among young people. It was emphasised that vaping should support quitting smoking rather than act as a gateway behaviour.

·       Concerns were raised regarding access to and availability of products such as shisha and vaping products within communities.

AGREED:

1.     That the report be noted and the recommendations to Scrutiny be supported.

2.     That comments made by members of this commission to be taken into account.

3.     That a further update be brought back to the Commission on progress, including delivery against the action plan and any measurable impact on outcomes.