CDOP Briefing Paper 1: March 2016

CDOP Briefing Paper 1: March 2016

This paper captures stories of interest that have arisen since the last meeting and that we feel the panel may wish to discuss or comment on:

Child Accident Prevention Trust Newsletter (February 2016)

Cot Bumpers: Parents of babies are being advised to remove cot bumpers from their babies’ cots after a study published by the Journal of Pediatrics showed they can be a potential choking, suffocation and strangulation risk. Following publication of the study, The Lullaby Trust (formerly the Foundation for Sudden Infant Death) sent out a clear warning to parents to remove cot bumpers. More information is available on The CAPT website.

Button Batteries: Following the death of a two-year-old girl on Boxing Day, CAPT are scaling up their campaign on button batteries. More information about the hazards of button batteries and the actions that are being taken are shown on the CAPT website.

SE/SW CDOP Managers Meeting – January 2016

Safer Sleeping Research

Anna Pease is a PhD student who has recently completed a research project funded by The Lullaby Trust to gain a greater understanding of the reasons why some Mothers who meet the main high risk indicators for SIDS, sometimes choose NOT to follow the safer sleep advice that is given to them.

One of the core and recurring features of this research was that Mothers in the High Risk categories will not trust the advice that they are being given by professionals unless they are given clear and compelling reasons for taking a particular action. It was observed that sometimes front line practitioners simply give out guidance to Mothers without explaining the reasons WHY it is best to place a baby on its back and what the consequences could be of not doing this. The group felt that CDOPs needed to think again about how these important messages are being communicated to Mothers and how we can provide higher risk Mothers with practical strategies for fulfilling these guidelines within the unique context of their own living environment. A set of slides from this presentation are available from

Presentation from ROSPA

Sheila delivered an excellent presentation to the group on the work of ROSPA to address the issues of child deaths in the UK related to suffocation with Nappy Sacks (16) and death by Blind Cords (29). A copy of the presentation slides are available from

SM also told the group about a very useful NHS video on youtube that has been produced by Cornwall and Isles of Scilly NHS giving guidance on the dangers of both nappy sacks and blind cords https://www.youtube.com/watch?v=0PrfoS_RCDA

National CDOP Conference – Birmingham – 17 February 2016

The second National CDOP conference was held in Birmingham last month and was attended by CDOP Reps from across England. WSSCB CDOP reps were Annette Lawrance- Owen (Specialist Nurse Rapid Response) and Maggie Pugh (CDOP Co-ordinator). Key themes that emerged from the day included:

There was a strong feeling expressed by specialists (speakers) at the event that Neonatal deaths should be reviewed separately by a specialist medical CDOP team that includes an obstetrician and a midwife. It was felt that there was a lot that could be learnt from these reviews. Current data for neonatal deaths shows that 16% are due to perinatal asphyxia and 29% due to prematurity. The question posed was “Can we do something about these?”

It was also suggested that all Child Death Reviews should be held within Hospitals and include representatives of all Health agencies who were involved in the child’s care pathway. In England most children die in Hospital, the largest proportion of child deaths occur in the neonatal period where most die either from the consequences of perinatal complications or from congenital abnormalities. There are a substantial proportion of child deaths in children with life-limiting conditions. Representation on CDOP panels should be reflecting the case mix of children being discussed to ensure that decisions regarding contributing factors and modifiable factors are properly informed - otherwise there is a risk that recommendations will lack credibility. Question “do we have sufficient Health representation on our CDOP?”

The presentations from the National Conference will be made available to the panel once they have been published on the CDOP National Network site.

Maggie Pugh

CDOP Co-Ordinator