Oxfordshire Child Death

Overview Process

Annual Report for 2014/15

Oxfordshire Child Death Overview Process

Annual Report for 2014/15

Contents / Page Number
Introduction from the CDOP Chair / 3
Background / 4
CDOP Activity / 4
Comparison with Statistical Neighbours / 5
Modifiable Factors / 7
Unexpected deaths and the rapid response / 10
Update on last year’s recommendations / 11
Recommendations for 2014/15 / 11
Conclusion / 12
Appendix 1Child Death Overview Panel Membership / 13
Appendix 2Responsibilities of Child Death Overview Panels / 14
Appendix 3Budget / 14

Purpose of the Report – from the Chair

This is the annual report of the Oxfordshire Child Death Overview Panel (CDOP). The report aims to set out the CDOP work, during 2014-15 and its future plans.

Deaths in children are always very distressing for parents, carers and clinical staff.Understanding the causes of childhood deaths can lead in some instances to effective action in preventing future deaths. Our aim is to review deaths of all children in Oxfordshire and identify themes, modifiable factors and any issues that may affect the safety and welfare of the children in Oxfordshire. In particular we aim to develop a more detailed understanding of the causes of death and where appropriate take forward recommendations made by the panel to influence strategic changes.

The Oxfordshire CDOP will continue to work within the principles underlying every child’s death which are:

  1. Every child’s death is a tragedy
  2. We must continue to learn lessons from child death reviews.
  3. Continue essential joint agency working
  4. Continue to ensure that all agencies take positive action to safeguard and promote the welfare of children

The CDOP has representation from a number of agencies and professionals and I am grateful for the commitment of all those who are involved in this process and who attend panel meetings, contribute to the analysis of cases andundertake a range of supporting tasks.To provide additional scrutiny to the work of the panel we have recruited a lay member to join the membership who will be joining the panel in July 2015.

Interagency communication continues to be an essential aspect in achieving productivity and maintaining strong working relationships at all stages of the child death review process, it is through these relationships that we will continue to improve service delivery to bereaved families across Oxfordshire. Once again it is important to recognise the important contribution the rapid response team make not only to the CDOP review but to the immediate response provided in the event of an unexpected child death. This difficult and sensitive work forms an essential part of the overall working of the CDOP and ensures support for families and professionals. I would like to take this opportunity to thank each of the members of the rapid response team and all the many agencies that have attended rapid response meetings, ensuring that robust procedures are in place for families to be supported in the tragic circumstances surrounding a child death.

This report is agreed by the Child Death Overview panel. It is integrated within the Oxfordshire Safeguarding Children Board (OSCB) annual report and is shared with Oxfordshire Clinical Commissioning Group Quality and Performance Sub-Committee.

Sula Wiltshire, Chair of the CDOP

Director of Quality and Lead Nurse, Oxfordshire Clinical Commissioning Group.

Background

The Local Safeguarding Children Board (LSCB) functions in relation to child deaths are set out in Regulation 6 of the Local Safeguarding Children Boards Regulations 2006, made under section 14(2) of the Children Act 2004. The LSCB is responsible for:

a) collecting and analysing information about each death with a view to identifying -

(i) any case giving rise to the need for a review mentioned in regulation 5(1)(e);

(ii) any matters of concern affecting the safety and welfare of children in the area of the authority;

(iii) any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area; and

(b) putting in place procedures for ensuring that there is a coordinated response by the authority, their Board partners and other relevant persons to an unexpected death.

Working together to Safeguard Children (March 2015) chapter 5 lays out the LSCB responsibilities and the processes it is required to follow in relation to the death of any child. These responsibilities include:

  • Ensuring that a review of each death of a child normally resident in the OSCB area is undertaken.
  • Ensure that there is a partnership approach and multi-agency involvement in reviews that must include a professional from public health.
  • Complete and return all nationally agreed forms
  • Ensuring the aggregated findings from all child deaths inform local strategic planning
  • Preparing an annual report of relevant information for the OSCB that in turn informs the OSCB annual report

The CDOP is committed to the process of systematically reviewing all children’s deaths ensuring the child death review process is grounded in respect for the rights of children and their families, and focused where possible on preventing future child deaths.

The panel has a fixed core membership which is detailed in Appendix 1. TheCDOP has the flexibility to co-opt other relevant professionals as and when appropriate. The CDOP members comprise of representatives from key partner agencies, to provide expertise on a wide range of issues pertinent to children’s services. The CDOP usually reviews between 6 and 10 cases at each meeting completing the national Form C for each case.

  1. CDOP activity in 2014/15.

In 2014/15, 92 child deaths were reported to the Oxfordshire child death overview team and were discussed with the designated doctor for child death. 40 of the child deaths reported were of children normally resident in Oxfordshire and 52 of the deaths were of children normally resident in other counties. The information on each child’s death is collected and collated. Relevant information relating to the death of non-Oxfordshire children being passed to the relevant designated single point of contact and named professional for child deaths from the child’s normal area of residence.

In 2014/15 the Oxfordshire CDOP reviewed the deaths of 38 children who usually reside in Oxfordshire. These reviews included 19 deaths that occurred in the year 2014-15 and 19 reviews that occurred before 2014 but had been carried over due to alternative processes and investigations that prevented completion of the CDOP process.

Not all of the child deaths occurring in 2014-15 have been reviewed by the CDOP, 3 cases are carried over to the 2015-16 year. Where other processes need to be completed e.g.criminal investigations, Coroner’s investigations, individual internal agency enquiry there can be a gap of several months between a death and that death being reviewed.. Outstanding cases are discussed and remain on the agenda of the rapid response case discussion meetings to ensure that necessary action plans are being completed and the families are kept up to date and supported through the process.

Table 1:Number of all deaths notified to Oxfordshire CDOP in 2014/15

Residency of children / All deaths / Expected / Unexpected / TBD* / Deaths
Occurringin-county / Deaths Occurringout-of-county
Oxfordshire / 40 / 25 / 15 / 35 / 5
Non-Oxfordshire / 52 / 45 / 5 / 2 / 52 / 0
Total / 92 / 70 / 20 / 87 / 5

*TBD = deaths that at the time of reporting were not confirmed as expected or unexpected.

Details of those cases reviewed are described in the report below.

Comparison with Statistical Neighbours:

Over the last two financial years there has been no significant change in the number of child deaths in Oxfordshire, as shown in the chart below which compares the number of deaths over the past 8 years.

Chart 1: Number of deaths, Oxfordshire children aged 0-18 years,

2006 – 2014/15

At the time of this report the relevant data to compare Oxfordshire figures with that of our statistical neighbours for 2014/15is not yet not available. These figures will be analysed and any variation reported to the OSCB once available.

The child deaths are all categorised and assigned a cause of death according to a national descriptor by the child death overview panel. The tables below show the category (table 2) and causes (table 3) agreed by the panel for the reviews undertaken in the year 2014-2015. The panel alsoidentifies whether there were any modifiable factors that may have impacted on the child. These are assessed to determine whether they may have contributed to the death, or were incidental, these are described in more detail in the section below.

Table 2: Category of death reviewed by Oxfordshire CDOP on behalf of the OSCB between 2014/15

Number of child deaths with modifiable factors recorded under this category of deaths / Number of child deaths with NO modifiable factors recorded under this category of deaths / Number of child deaths where there was insufficient information to assess if there were modifiable factors.
Deliberately inflicted injury, abuse or neglect (category 1) / 2 / 0 / 0
Suicide or deliberate self-inflicted harm (category 2) / 0 / 1 / 0
Trauma and other external factors (category 3) / 3 / 3 / 0
Malignancy (category 4) / 0 / 0 / 0
Acute medical or surgical condition (category 5) / 1 / 0 / 0
Chronic medical condition (category 6) / 1 / 4 / 0
Chromosomal genetic and congenital anomalies (category 7) / 0 / 8 / 0
Perinatal / neonatal event (category 8) / 5 / 4 / 0
Infection (category 9) / 1 / 3 / 0
Sudden unexpected, unexplained death (category 10) / 2 / 0 / 0
Unknown Category / 0 / 0 / 0
Total / 15 / 23 / 0

Table 3: Cause of child deaths reviewed by the Oxfordshire CDOP between 2014/15

Number of child deaths with modifiable factors recorded under this event / Number of child deaths with no modifiablefactors recorded under this event / Number of child deaths where there was insufficient information to assess if there were modifiable factors
Neonatal death (B2) / 5 / 4 / 0
Known life limiting condition (B3) / 1 / 12 / 0
Sudden unexpected death in infancy (B4) / 2 / 0 / 0
Road traffic collision (B5) / 0 / 0 / 0
Drowning (B6) / 0 / 0 / 0
Fire and burns (B7) / 0 / 0 / 0
Poisoning (B8) / 0 / 0 / 0
Other non-intentional injury / accident/ trauma (B9) / 4 / 3 / 0
Substance misuse (B10) / 0 / 0 / 0
Apparent homicide (B11) / 0 / 0 / 0
Apparent suicide (B12) / 0 / 1 / 0
Other / 3 / 3 / 0
Total / 15 / 23 / 0

Modifiable factors

The guidance outlined in Chapter 5 in Working Together to Safeguard Children 2015defines “preventable child deaths as those in which modifiable factors may have contributed to the death. These factors are defined as those which by means of nationally or locally achievable interventions could be modified to reduce the risk of future child deaths”.

The CDOP considers modifiable factors, such as those in the family and environment, parenting capacity or service provision, and consider what action could be taken at a regional or national level to prevent future deaths and improve service provision to children, families and the wider community.

The CDOP concluded that there were 8 modifiable factors, arising from fourteen cases:

Modifiable factors identified included the following:

  • Co-sleeping
  • Alcohol consumption in pregnancy
  • Smoking by the partner/in home environment
  • Bicycle not road worthy
  • Smoking in the antenatal period
  • Alcohol consumption in the postnatal period
  • Safe storage of nappy sacks
  • Substance misuse

As a result of the identified modifiable factors the following specific recommendations was made by the CDOP:

  • Schools should ensure that road safety education is provided to all pupils
  • Maternity staff ensure mothers have information on safe sleep guidance and safe nappy sack storage
  • OSCB should be assured that Health and Safety assessments required for operating heavy machinery are being undertaken.
  • OSCB should advertise training to health professionals in relation to the issues around young people and substance misuse.
  • Guidance for schools dealing with suicide clusters to be produced
  • The importance of taking folic acid in pregnancy needs to be highlighted to new mothers

No specific recommendations to address the other modifiable factors were made due to campaigns already well established and on-going.

Additional analysis of the child deaths has been undertaken to review the data in relation to age, gender, ethnicity, location where the death occurred and home address. This is shown below

Chart 2 the age and gender of the Oxfordshire child deaths reviewed in 2014/15

Table 4Ethnicity of the children reviewed by the Oxfordshire CDOP in 2014/15

Ethnicity / Expected / Unexpected
White British / 7 / 5
British / 3 / 6
White Other / 1 / 1
British African / 0 / 1
British Carribbean / 0 / 1
Mixed Race / 0 / 1
British Pakistani / 1 / 0
Pakistani / 1 / 0
Unknown / 7 / 3
Total / 20 / 18

Table 5: Location of child at the time of their death, as reported to Oxfordshire (CDOP), in 2014/15

Location of fatal events / Oxfordshire / Non-Oxfordshire
Home / 5 / 1
Public place / 4 / 1
Hospice / 5 / 5
JR Neonatal Intensive Care Unit / 8 / 25
JR Paediatric Intensive Care Unit / 6 / 9
JR Emergency Department / 3
JR Maternity Ward / 4 / 5
Horton unit / 3
Non-Oxfordshire hospital unit / 2
Not recorded / 6
Total / 40 / 52

Chart 3 the recorded residential address of the child at the time of their death

  1. Unexpected deaths and rapid response in Oxfordshire

Working Together to Safeguarding Children 2015requires that a rapid response process should be provided to all families where a child has died unexpectedly. In Oxfordshire, the rapid response service is now well established and assists in gathering as much information as possible in a timely and systematic yet sensitive manner to inform understanding of why the child has died.The rapid response team has an on-call rota to cover the service 24 hours a day 7 days a week including bank holidays. The rapid response service continues to be successfully provided by the Chaplaincy and Bereavement Team at the John Radcliffe Hospital. The Safeguarding Services Manager is also part of the rapid response team.

In collaboration with the Designated Doctor for Child Deaths the Rapid Response team provide support to families, professionals and the wider community in the event of a sudden and unexpected child death. The Rapid Response team have continued to work collaboratively with other organisations including the Coroner’s office, Schools, Youth Projects, Social Care, South Central Ambulance Service, Thames Valley Police, Oxford University Hospitals NHS Trust, Oxford Health NHS Foundation Trust, Helen and Douglas House Hospice and the child bereavement charity SEE SAW, in order to enhance the quality of care provided to all those whose work brings them into contact with bereaved families.

Home visits take place in consultation with Designated Doctor for Child Deaths andother responding agencies including the Coroner’s Officer. Home visits have helped to identify a range of factorsthat may have contributed to a child’s death and also ensured the safety and welfare of siblings. The home visits also assist in confirming family health information and ensure that potential gaps in service provision are filled.These home visits inform the rapid response multi-agency meeting and assist in developing a programme of support based on the family’s particular needs as well as providing extended support and information to other agencies involved with the family.

The Designated Doctor for child deaths chairs the rapid response meetings ensuring that the principles underlying the rapid response are considered throughout by all agencies. The principles underlying the rapid response continue to be:

  1. The family must be at the centre of the process, fully informed at all times, and treated with care and respect.
  2. Joint agency working draws on the skills and particular responsibilities of each professional group.
  3. A thorough systematic yet sensitive approach will help clarify the cause of death and any contributory factors.
  4. The “Golden Hour” principle applies equally to family support and the investigation of the death.

In 2014/15, a total of 20 unexpected deaths were reported to the Oxfordshire CDOP and rapid response team. Of these 15were of children normally resident within the Oxfordshire.

A summary of the action taken by the Oxfordshire rapid response team for children normally resident in Oxfordshire is detailed below.

Rapid Response for children following unexpected death normally resident in Oxfordshire 2014/15: 15 cases this year

  • Number rapid response cases Subject to strategy discussion = 15
  • Number of rapid response meetings = 14 (one case was subject to other processes)
  • Home Visits = 9
  • Gender: Boys=9 Girls = 6

In all cases the Coroner was informed of the child’s death in a timely manner. The rapid response team have a target response time frame of two hours from the receipt of notification, this target has been reached in 100% of cases in 2014/15.All families received both practical and emotional support including advice on financial difficulties where appropriate.

The 5 unexpected out of area cases were referred to the relevant LSCB at the earliest opportunity with further information provided to the relevant area by the child death overview manager following discussion and advice from the designated doctor for child death. All of the families received immediate bereavement care and support from the Oxfordshire rapid response team

  1. Update on last year’s recommendation

The CDOP considered issues arising from its review of all the deaths of Oxfordshire children; in the year 2013/14.The outcome of the recommendations by the panel are:

  • The safeguarding service manager obtained and shared details of water safety leaflets It was recommended that this formed part of child safety week activities.
  • Oxfordshire Sports Partnership added to its safeguarding training a case scenario about alcohol cultures within sports settings and about the issue of private hire of their premises. This was to raise awareness of the issues linked with under age drinking and mental well-being.
  • There have been discussions between Oxfordshire Family Liaison Officers the Safeguarding Services Manager and See Saw on the rapid response process, responding to a child death and the impact on child witnesses. This has resulted in improved understanding and clarification of roles and stronger working relationships
  • There has been work within bereavement teams to identify when support is required for young people and children who are witnesses to a child death to minimise Post Traumatic Stress Disorder.In situations when a child is a witness consideration is now given to the capacity of the child to give evidence and this capacity is discussed at the a rapid response meeting to ensure appropriate support is in place.
  1. CDOPrecommendationsfrom cases reviewed in 2014/15:

During 2014/15 the following recommendations and actions resulted from CDOP reviews: