Child Death

The Derby Safeguarding Children Board has a statutory responsibility to review the deaths of all children under the age of 18 years who are residents in the area. This includes children who die abroad or in another part of the country, and excludes stillborn babies.

The local Child Death Overview Panel (CDOP) is a joint group with the Derbyshire Safeguarding Children Board. It supports the documentation of child deaths and identification of patterns in a community so that any preventable hazards may be identified and reduced. The panel are also responsible for disseminating any lessons to Safeguarding Boards and other relevant stakeholders across the county.

Between 1st April 2013 and 31st March 2018, there were 307 completed cases of child deaths that were evaluated by the panel. Modifiable factors were identified within 43 of these cases (14%), which suggests that these could have been prevented. The CDOP identified that the most common factors across modifiable cases were acute/sudden onset illness and prior medical intervention. This was followed by other chronic illness, access to health care and smoking by a parent/carer.

In-depth analyses revealed clear differences in the characteristics of children within the modifiable and non-modifiable cases. These stemmed from: 1) deprivation 2) location of death and 3) safeguarding issues.

Deprivation

Local deprivation quintiles were calculated by first extracting the child’s index of multiple deprivation (IMD score) from their lower super output area (LSOA) of residence. The LSOAs were then sorted from the most to the least deprived, before being divided into quintiles. 54% of modifiable cases (n=102) originated from the more deprived local quintiles of 1 and 2. Non-modifiable cases appeared to show a more even spread across the deprivation quintiles.

Location of death

29% of modifiable factors arose in an acute hospital, whilst the home was the most common location within modifiable cases (33%).

Safeguarding issues

A markedly higher proportion of children within modifiable cases had associated safeguarding issues than those within non-modifiable cases.

The following actions have been implemented between April 2017 and March 2018:

1. Promotion of safe sleeping practices. Royal Derby Hospital have produced a BASIC (BAby Safe In Cot) infographic that encourages safe sleeping practices in the hospital.
2. Investigation into the risk factors for sudden neonatal deaths in hospital. Royal Derby Hospital have developed a ‘Newborn Thermal Care Safety Bundle’ to help prevent avoidable admissions to the neonatal intensive care unit.
3. The announcement of major retailers, (including Morrisons) to put warning labels onto the packaging of nappy sacks. This has arisen following local partnership working with the Royal Society for the Prevention of Accidents (ROSPA).
4. The delivery of a community workshop on cousin marriage on behalf of CDOP to a group of Pakistani Muslim women resident in the Normanton area of Derby.
5. A review of processes to ensure a rapid review of child deaths in future.