Child Death Overview Panel and Rapid Response

City and Hackney

Dr Carla Stephen, Designated Dr for Child Death

Children’s Services, Homerton University Hospital

22.11.13

Aims of session

At the end of this session you should be able to

• Understand the role of your local CDOP • Understand the rapid response process and

the contribution you can make• Be aware of the activity of your local CDOP

Background• England is the first country to have national

procedures for review of all child deaths.

• Response to Inquiry into death of Victoria Climbie and the Every Child Matters Green Paper, 2003.

• Introduced in Working Together to Safeguard Children, 2006.

Background• Children Act 2004 & Working Together 2006

– Creation of Local Safeguarding Children Boards (LSCBs) by 2006

– LSCBs to review all child deaths in their area– LSCBs convene a CDOP for this purpose

• Coroner’s Rules 1984 amendment in July 08– Duty to notify deaths to LSCB– Power to provide information about deaths to

LSCB

Background

• Children and Young Persons Act 2008– Registrars given duty to inform LSCB of death

certificate information– Registrar General given duty to inform Secretary

of State of all child deaths whether here or abroad

• These powers allow for flow of information but their use depends on interpretation

Why review all deaths?

• Evidence based interventions to prevent child deaths

• Public health information about patterns of child death

• Interagency working to safeguard children and promote their welfare

• Statutory requirement, moral imperative and public expectation to promote learning and transparency

CDOPCity and Hackney CDOP

• Subcommittee of CHSCB• Operating 6yrs• Reviewed total of 153 deaths • Deaths of all children under 18yrs resident in

Hackney reviewed – includes <23/40 gest

• Determines any modifiable factors in prevention of death

• Standardised national dataset

CDOPMultidisciplinary panel

• Independent chair –Dep Dir Public Health

• Health• Paediatrics, Neonates, Paediatric Pathology,

General Practice, mental health, safeguarding, nursing and midwifery

• Social care – Children’s Social Care

• Police - CAIT

• Education - HLT

• Youth crime reduction • Coordinator

CDOP

Core Functions• Prevent future deaths• Id risks and trends assoc with child death• Timely, accurate cause of death reporting• Ensure rapid response for unexpected

deaths• Liaise with agencies about preventable

factors and lessons learned

CDOP

Core Functions• Advise CHSCB re training/resources for

interagency working• Share information with Police and Coroner• Notify CHSCB if s47 or SCR needed• Collate and submit minimum datasets• Locally implement regional/national

initiatives

CDOP Procedure• Notification of death to SPOC (Kerry Littleford)

• Notification protocol – multiagency Form A• Request for information via Form B• Form C prepared by SPOC • Unexpected deaths managed through RR• Expected deaths discussed at quarterly

CDOP meetings• Deaths classified and modifiable factors det.• Publication in anonymised form annually

Rapid Response

• Subcommittee of CDOP which considers all unexpected child deaths i.e. not expected within previous 24hrs or unanticipated collapse leading to death

• Functions– Enquire into reasons and circumstances of death– Identify and safeguard other children in the home– Understand and challenge organisation’s roles – Bereavement support for family– Collect standardised data set and report to CDOP

Rapid Response Procedure• Notification of death to SPOC• Notification of death to local agencies by protocol• Request for information from agencies- Form B• Decision taken by Designated Dr for Child Death to

call a Rapid Response meeting – usually within 1 wk of notification.

• Submission of information about child and family held by agencies to SPOC and CDOP

• Coroner investigates death and post mortem carried out as appropriate

Rapid Response Procedure• Meeting chaired by Des. Dr for Child Death • Professionals meet to share information and discuss

post mortem preliminary results if available• Whole life history of child and family considered • Areas of risk/concern identified and

recommendations made• Minutes circulated and further information gathered • Second meeting may be called to discuss final post

mortem results • Findings submitted to CDOP for classification.• Referral for SCR made to SCR Subc where needed

CDOP 2012-13

City and Hackney

* Child and Maternal Health Observatory - Chimat, 2013

C&H England

Children under 5y 7.6% 6.3%

Children under 18y 24.6% 23.9%

Infant mortality rate (per 1000 live births)

5.0* 4.4*

Child mortality rate(per 100,000 children)

22.6* 13.7*

CDOP 2012-13• 33 new deaths reviewed – 13 unexpected• 46 cases reviewed – 40 completed• No SCRs• Modifiable factors identified in 2 (5%)

– Cosleeping, Vit D deficiency

2010-11 2011-12 2012-13

Rapid response

12 4 13

Modifiable factors

12/48 6/30 2/40

CDOP 2012-13

Profile of completed reviews• Most were male M:F 28:12 (70%:30%)• Most were neonates 25:15• Most of the rest were infants(over 28d) 9/15

• All but 2 of the deaths were children ≤ 5y

CDOP 2012-13

Age and Gender of Deaths in 2012-13

CDOP 2012-13

Causes of Death in 2012-13 (WHO ICD-10)

CDOP 2012-13

CDOP 2012-13

• Most deaths from peri/neonatal causes were in those <26/40

• 2 SUDI deaths ( 1 SIDS, 1SUPC)

Peri/Neonatal deaths – completed cases

CDOP 2012-13 Ethnicity of Cases 2012-13

Black population over-represented- 37% vs 21% popn

CDOP 2012-13Geographical variation

• City of London – 0 deaths• Hackney – no statistical difference

between areas of varying Multiple Deprivation scores

Seasonal variability• Slight increase in spring and autumn but

not statistically significant

RR 2012-13

Unexpected deaths• 13 had rapid response• 4 SUDI, 1 drowning, 7 morbid conditions• 1 death not yet categorised• 2 modifiable factors – infants

• Cosleeping • Vit D deficiency

RR 2012-13

CDOP 2012-13

0

1

2

3

4

5

Causes of Unexpected Deaths

CDOP 2012-13

• Cardiac deaths - 4• Cardiomyopathy, MI post transplant, HLH

• Asthma

• TTP

• Infection in child with cong. neuro abn

• SUDI • 3 SIDS, 1 SUPC

CDOP Recommendations• Sharing hospital discharge summaries with

Community services• Ensuring family referral for genetic

counselling where appropriate• Completed review of A&E fever management

policy for premature infants• SIDS staff training via FSID and in children’s

centre staff newsletter• Asthma integrated care pathway • Universal Vit D supplements via Healthy Start

Your Contribution as GP

• Provide information about child and family (Form B)

• general health, specialist input, antenatal info, compliance (medication, vaccines), mental health of parents, family dynamics, safeguarding concerns

You may know that family the best!

• Attending rapid response meeting• Bereavement support• Arranging referrals/screening for family• Implementing learning into practice

“…..Every family has the right to have their child’s death properly investigated. Families desperately want to know what happened, how the events could have occurred, what the cause of death was, and whether it could have been prevented. This is important in terms of grieving”.

Baroness Helena Kennedy QC, 2007.

Useful contactsMarcia Smikle, Head of Nursing – Community

marcia.smikle@homerton.nhs.uk Tel: 0207 683 4691/4314

Kerry Littleford, CDOP Coordinator and SPOC

kerry.littleford@hackney.gov.uk Tel: 0208 356 4175

Dr Carla Stephen, Designated Dr for Child Death carla.stephen@homerton.nhs.uk Tel: 0207 683 4772