Agenda item

To receive the Child Death Overview Panel Annual Report and a presentation from Alison Johnson, Designated Nurse Safeguarding Children, North East & North Cumbria Integrated Care Board.

Members received the Child Death Overview Panel (CDOP) Annual Report and a presentation from Alison Johnson, Designated Nurse Safeguarding Children, North East & North Cumbria Integrated Care Board.

Alison Johnson raised the following key points:-

•       The role of the Panel included

•       review the death of every child normally resident in the area regardless of where death occurred.  The report on all children whose deaths had been reviewed in 2021/22 regardless of the year in which they died.

•       There was a statutory duty to scrutinise each case and challenge the agencies involved to enhance learning and improve service delivery and patient experience.

•       Determining the contributory and modifiable factors and make recommendations to all relevant organisations.

•       The total number of death notifications for Northumberland in 2021/22 was 19 in comparison to 16 in 2020/21 with 10 being reviewed.  Circumstances such as police procedures may delay the review of a death.  In six cases, modifiable factors were identified.

•       Modifiable factors identified included:-

•       Parental smoking, missed immunisations, delays in diagnosis, maternal obesity during pregnancy, unsafe sleeping arrangements, and failure to recognise vulnerability in young people.

•       The Designated Nurse Safeguarding Children would be informed of any themes and modifiable factors relating to the review of the death of a Northumberland child in order to share these with appropriate organisations.

The following comments were made:-

•       There appeared to be an increase in male deaths, however, it was difficult to identify any trend with such small numbers and only over a two year period.

•       There was an increasing trend to include the deaths of very premature children who would not have survived as well as still births at term.  It was important to consider delineating between the two, whilst it did not diminish the tragedy for families of the first.

•       It was noted that the governance of the CDOP annual report formerly lay with the Safeguarding Partnership and now lay with the Health & Wellbeing Board.  This was important to note in relation to the modifiable factors that these needed to be explicitly taken on by the Health & Wellbeing Board.

•       The reviews undertaken by the CDOP were looked at as isolated events whereas there was a need to consider whether there were clusters in particular communities and modifiable factors such as smoking.  This could be taken into family hubs.

•       Health Visitors did a comprehensive assessment commencing in the ante natal period and a home environment assessment was built into this working with parents about sleep habits and risk factors.  Action plans were built into the assessment process.

•       The CDOP report had been shared with the Tobacco Partnership.

•       The Registrar service was based within Family Hubs in Northumberland and holistic, wraparound service could be offered for bereaved families.

•       Child immunisation rates in Northumberland had always been good and above the national average.

•       Parents were informed that their child’s case was being reviewed but not about any modifiable factors which were identified.

•       It was important that all Members should take this report back to their organisations to ensure that they were working to the best of their ability regarding children and young people.

RESOLVED that the report and presentation be received.