Enfield CDOP Learning Event ... because safeguarding children is everyone’s responsibility Enfield CDOP Learning Event November 5th 2015 Twitter @EnfieldSCB #EnfieldCDOP Wifi –

… because safeguarding children is everyone’s responsibility

Enfield CDOP

Learning Event November 5th 2015

Twitter @EnfieldSCB

#EnfieldCDOP

www.slido.com

#EnfieldCDOP Wifi – LBE Guest

Username – CDOP05

Password: USKG7084

https://twitter.com/EnfieldSCB/

http://www.slido.com/


Geraldine Gavin

Enfield Safeguarding Children

Board Independent Chair


Interact We are using sli.do at today’s conference

Take out your smart phones and connect to the internet:

Open a web browser

Go to www.slido.com and enter the event code

#EnfieldCDOP

Easily summit your questions and express your opinion by

voting on live polls.

You can also use Twitter…

Twitter @EnfieldSCB

#EnfieldCDOP

http://www.slido.com/


Child Death Overview Panel

Dr. Allison Duggal

Consultant in Public Health & Chair of CDOP

Christina Keating Designated Nurse for

Safeguarding Children

Grant Landon

ESCB Business Manager


Background • England was 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 and repeated in revisions up

to March 2015

https://www.gov.uk/government/publications/working-together-to-safeguard-children--2










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 2008

– Duty to notify deaths to LSCB

– Power to provide information about deaths to LSCB

http://www.legislation.gov.uk/ukpga/2004/31/contents






http://www.legislation.gov.uk/uksi/2008/1652/pdfs/uksi_20081652_en.pdf














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













Exercise

Consider the questions on your

tables. Discuss with others on

your table and be prepared to

feedback your responses


Questions 1. What constitutes a child death that would be

considered by CDOP?

2. How do you notify CDOP of a child death? Consider

Who? Why? What? When?

3. What is the difference between an expected and

unexpected death?

4. What is a Rapid Response Meeting? What is its

purpose? Who should attend?

5. What is the Child Death Overview Panel? What is its

purpose? What should attend?


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


Enfield CDOP

• Sub-committee of ESCB

• Operating 7yrs

• Received 241 notifications to date

• Reviewed total of 222 deaths

• Deaths of all children under 18yrs resident in Enfield reviewed –

includes >23/40 gestation

• Determines any modifiable factors in prevention of death

• Bereavement support needs for family & professionals

• Standardised national dataset


CDOP

Multidisciplinary panel • Chair – Public Health Consultant

• Health

• Paediatrics, Neonates, General Practice, Mental

Health, Safeguarding, Nursing and Midwifery,

Health Visiting

• Social care – Children’s Social Care & Safeguarding

Board

• London Ambulance Service

• Police - CAIT

• Education


CDOP

Core Functions • Prevent future deaths

• Identify risks and trends associated with child

death

• Timely, accurate cause of death reporting

• Ensure rapid response for unexpected deaths

• Liaise with agencies about preventable factors

and lessons learned

• Bereavement Support


CDOP

Core Functions • Advise ESCB re training/resources for interagency

working

• Exchange of information with Police and Coroner

• Advise ESCB regarding s47 or SCR processes

• Collate and submit minimum datasets

• Locally implement regional/national initiatives

• Interface with Serious Case Review Subcommittee


CDOP Procedure • Notification of death to SPOC

• Notification protocol – multi-agency Form A

• Request for information via Form B

• Unexpected deaths managed through Rapid

Response Meeting

• Expected deaths discussed at quarterly CDOP

meetings

• Deaths classified and modifiable factors determined.

• Form C Analysis prepared by CDOP coordinator post

case reviews

• 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 & professionals

– 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 Paediatrician for Child

Death to call a Rapid Response meeting – usually

within 5 working days 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 Designated Paediatrician 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 Subcommittee where needed


CDOP Statistics

Number of Deaths 2014-5

• There were 17 deaths reviewed between 1 April 2014

and 31 March 2015

• 3 deaths were found to have modifiable factors

• There were no SUDIs

• No deaths were referred to Serious Case Review


CDOP Statistics

Gender Category of Death

Male

Female

information notavailable

Trauma and otherexternal factors

Malignancy

Acute medical orsurgical condition

Chronic medicalcondition

Chromosomal,genetic andcongenital anomalies

Perinatal/neonatalevent

Infection


CDOP Statistics

Age at Death 2014-5

Time Taken from Death to

Panel Discussion

0-27 days

28-364 days

1-4 years

5-9 years

10-14 years

15-17 years

>4 years

Between 3 and 4years



Within one year


“…..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 Contacts

Enfield Single Point of Contact – Jean Rogers beh-tr.enf-pct-

[email protected] 020 8702 5600

Enfield CDOP Coordinator – Aileen Ingram [email protected] or

[email protected] 020 8379 3012

Bliss - www.bliss.og.uk

Child Bereavement UK-www.childbereavement.org.uk

Child Death Helpline - www.childdeathhelpline.org.uk

Lullaby Trust - www.lullabytrust.org.uk

Sands - www.uk-sands.org.uk

Winston’s Wish - www.winstonswish.org.uk

Grief Encounter - www.griefencounter.org.uk

mailto:[email protected]









http://www.bliss.og.uk/

http://www.childbereavement.org.uk/

http://www.childdeathhelpline.org.uk/

http://www.lullabytrust.org.uk/

http://www.uk-sands.org.uk/



http://www.winstonswish.org.uk/

http://www.griefencounter.org.uk/


ESCB Contacts

• Website - www.enfieldlscb.org

- lots of useful information for

professionals and families

• Twitter @EnfieldSCB

• Facebook - Enfield LSCB

http://www.enfieldlscb.org/


Infant deaths in Enfield with

a focus on SUDIs

Dr Justin Daniels

CDOP paediatrician, Enfield

November 2015


CDOP process

• Introduced 2008

• Operated in shadow form from 2007

• Rapid reviews for unexpected deaths


Data

• Looked at year 2008-9 to 2014-15

• 230 deaths 0-18

• 153 of these were under the age of 1


Deaths per year

0

10

20

30

40

50

60

70

80

2008-9 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15

under 1s

all



Deaths per year

• Change in coroners ruling

• Follows expected trend

• CMR 29/100,000 in 1983,10/100,000

2013


What did babies die of cause of deaths in under 1s

73

18

59 9 9

1611

1 2

0

10

20

30

40

50

60

70

80

prem

gene

tic /

cong

enita

l abn

orm

ality

met

abol

ic

infe

ctio

n

uncla

ssifi

ed

card

iac

sudi

perin

atal

traum

a

mal

igna

ncy



Comparative data

• On average there are just under 5,000

deliveries a year in Enfield.

• ONS data in brackets for 2012 and 2013

• This gives us:

• An infant mortality rate of 4/1,000 (3.8)

• A SUDI rate of 0.4/1,000 (0.3 )

• A childhood mortality rate of 0.13/1,000

(0.15)



SUDIs

• 16 in total

• No clear pattern over time

• mean age 195 days

• 2 ex prems

• If excluded – 75 days


Risk Factors • DH / NICE advice

• In a cot

• On back (not side or front)

• Feet to end

• Don’t bed share if premature, LBW, alcohol, smoker, drugs, tired

• Same room for first 6 months

• Never sleep on a sofa or chair with or without parent

• Don’t overheat



Risk Factors • 4 placed prone / side

– 1 reflux advice

– 1 found prone ? How placed

• 5 bed sharing with risk factors

– 2 prem

– 3 alcohol

– 1 smoking

– 2 probable drug usage


Risk Factors

• 3 sofa or chair sharing

– 1 with smoking and probable drug usage

• 2 were premature and found correctly

placed – both older with severe health

problems


Risk Factors

• 14 out of 16 had very clear risk factors

• Remaining two unclear history – one

multiple risk factors


Risk Factors

• Almost all babies had risk factors – not

surprising

• Does this mean that almost all

preventable?


Safe sleeping

• Anecdotally most parents know about

safe sleeping

• Why does practice differ ?

Documents

Enfield CDOP Learning Event ... because safeguarding children is everyone’s responsibility Enfield CDOP Learning Event November 5th 2015 Twitter @EnfieldSCB #EnfieldCDOP Wifi –