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 January 2013 and 31st March 2015, there were 149 child deaths – 115 of which were completed cases and evaluated by the panel in August 2015. Modifiable factors were identified within 26 of the 115 completed cases (23%), 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 other chronic illness. This was followed by factors relating to service provision – access to health care and prior medical intervention. The most common factors in the family and environment were smoking by a parent/carer in the household and smoking during pregnancy.

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.

Local deprivation quintiles were calculated by first extracting the child’s 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. 65% of modifiable cases (n=17) originated from the more deprived local quintiles of 1 and 2. On the other hand, non-modifiable cases appeared to show a more even spread across the deprivation quintiles.

Location of death
83% of incidents with no modifiable factors arose in an acute hospital, whilst the home was the most common location within modifiable cases (50%).

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 as a result of the recent CDOP review:

  1. Implementation of carbon monoxide monitoring for all pregnant women at the Royal Derby Hospital. This will help to identify those who do smoke, and subsequently ensure that they have timely access to smoking cessation services.
  2. The development and utilisation of an action log that will be shared in the near future.
  3. Identification of data quality issues that will assist in the development of a more robust database.
  4. Contribution to national consultation for a CDOP database. 
  5. Investigation into previous consanguinity trends. This will stimulate a more proactive approach towards the prevention of child deaths related to consanguinity.
  6. Discussions surrounding the integration of stillbirth reporting within CDOP. This will provide a broader perspective on the preventative measures required to address child deaths. 
  7. Partnership working with the Royal Society for the Prevention of Accidents (ROSPA). This has initiated upstream work, such as increasing the awareness of the nappy sac campaign.
  8. Promotion of key messages about keeping babies safe. A “keeping your baby safe leaflet” is currently being developed and piloted by parents.


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