The annual report of the Director of Public Health will be submitted to the Board for the years 2019/20 and 2020/21 as an appendix to the report (Document “A”).  

All Local Safeguarding Children Boards are required to have a Child Death Overview Panel (CDOP) to examine whether we can learn lessons from children’s deaths, in order to improve the health, safety and wellbeing of other children. Through this, we hope to prevent further child deaths and understand if there are modifiable factors that can prevent children’s deaths in the future.

Recommended –

·            That The recommendations from the CDOP report are enacted and considered by all partners. Proposed actions are summarised below and page 18 of appendix A also addresses actions that are already underway to address the issues identified below:

1.          Support national efforts to improve CDOP and child mortality registration (see national recommendations in appendix A: Figure 15)

2.          Reduce infant mortality in Bradford District through a coordinated response to reduce modifiable risk factors, specifically:

a.     Sudden Unexpected Deaths in Infants (SUDI) and unsafe sleeping arrangements

b.    Substance misuse / alcohol misuse by parents

c.     Parental mental health issues

d.    Genetic risk associated with consanguinity

e.     Parental Smoking

3.          Monitor child deaths that occur as a direct or indirect result of Covid-19 and make appropriate recommendations for action to Bradford District COVID Outbreak control board.

4.          Ensure safe swimming campaign messages are shared with the Living Well Schools programme ahead of summer and pro-actively ahead of predicted heat waves.

5.          To seek assurance that partners are working collectively on the suicide prevention agenda (and that bereavement support services are available to Children, Young People, and Families)

6.          Support efforts to reduce and mitigate against poverty and associated factors (domestic abuse, mental health, crime, poor and overcrowded housing, homelessness, access to services and benefits)

7.          Share the CDOP annual report findings and recommendations with strategic partnerships (Bradford District Well-Being Board, newly established Children and Young People & Family Partnership, and Children’s Safeguarding Board

(Joanna Howes – 07817 085954)

The annual report of the Director of Public Health (Document “A”) was submitted to the Board for the years 2019/20 and 2020/21.

Established in 2008, the CDOP was comprised of multi-agency professionals.  Its key functions included:

• To review all child deaths, excluding those babies who are stillborn and planned terminations of pregnancy carried out within the law
• Determine whether the death was preventable (if there were modifiable factors which may have contributed to the death)
• Decide what, if any, actions could be taken to prevent such deaths happening in the future
• Identify patterns or trends in local data and reporting these to the OSCB
• Refer cases to the OSCB Chair where there is suspicion that neglect or abuse may have been a factor in the child’s death. In such cases, a Serious Case Review may be required.
• Agree local procedures for responding to unexpected child deaths

Bradford District had established procedures and policies in place to ensure that it delivered its statutory CDOP duties.   The report appended to the main document provided details of the number and nature of child deaths including causes and whether they were considered to be modifiable.  It also provided a breakdown by demographic that included cause, gender, ethnicity and age per 10,000 along with indicative trends.  Sudden Infant Death in Infants (SUDI) statistics were also provided showing the cause and number of these and showed that unsafe (co-sleeping) was the most frequent cause of death.  Consanguineous union or marriage, where parents were related as second cousins or closer caused a local excess in congenital anomalies which were a leading cause of infant death and disability.

There were a number of recommendations and actions intended to prevent child death locally with details of the Better Births and Every Baby Matters programme and the work undertaken to reduce suicide in children and young people as well as the Learning Disability Mortality Review Programme.

The second part of the appendix document contained the membership of the CDOP and its Terms of Reference.

Officers provided a summary of the two-year report including the statistics relating to child deaths. Trends appeared to be stable despite a higher than national rate which were mainly infant mortality but four times higher than the national rate in the lowest quintile (most deprived) compared to the highest (least deprived).  Deaths were broken down into categories with the majority being from modifiable (preventable with action/intervention including co-sleeping in conjunction with drugs and alcohol).  Covid was not a major cause of death – 25 died of Covid.  Officers reported that there had been no suicides for children and young people in the district in the last 12 months.  Poverty remained a major factor as did the complexities of family backgrounds with education regarding consanguity being given to children of secondary school age to raise awareness and start to address the issue.

Members were then given the opportunity to comment or ask questions.  The details of which and the responses given are as below.

Members aspired to eradicate preventable deaths, to narrow the gap with national levels and to tackle unsafe sleeping and smoking.  This was a public health issue and various delivery mechanisms were proposed such as the use of Health Visitors and midwives who were already carrying out specific work relating to smoking along with information in GP surgeries, contraception services and sexual health services.  Safe sleep training was to be delivered alongside other local authorities and a new toolkit to train Health Visitors and Midwives would be available imminently.

Comments from members stated that intervention/wrap around was provided too late to tackle issues arising out of poverty and the right messages needed to be communicated to potential parents.  Modifying behaviours was not necessarily the top priority in some challenging family situations.

It was agreed that the training undertaken by the Early Years Alliance would be passed to the voluntary sector as they requested that the toolkit be shared with them also. 

It was acknowledged that data detailing the age of mothers when having their first and subsequent children was needed as part of gaining a better understanding of the demographics, therefore age information would be provided in future reports.

It was acknowledged that Health Visitors, Healthcare Workers and Midwives had a significant work load and skill sets were under review to create additional options and capacity across a number of organisations.

In relation to the local position versus national rates on modifiable and non-modifiable deaths, figures from some other areas and the type of questions asked plus the level of engagement impacted on data gathering and making direct comparisons.

An anti-poverty strategy would be launched in September 2022 and Members wanted to know if there were any practical things that could be done e.g. providing beds and cots etc. as overcrowding was a significant factor in modifiable deaths, it warranted consideration.  There was a brief discussion with how it could be achieved and the barriers to its implementation but with a number of suggestions to address them – such as using community champions who could provide information in different languages, and increased use of community centres, places of worship and pharmacies to support better early intervention.   

The representative from the Fire Service would be contacting colleagues in Manchester as they already had an effective training toolkit for water safety awareness to enhance the local materials West Yorkshire Fire Service already had.

Officers advised that a partnership was being developed to provide information and guidance via repeat messages on social media called ‘FYI’.  It was noted that ‘Whatsapp’ had been a valuable tool throughout the Covid pandemic.

A member stated that in response to potential workforce issues, that there was a plentiful supply of university students who could be trained to support and enhance the skill mix and that all students could be included regardless of the course they were studying.

Resolved –

·       That the recommendations from the CDOP report are enacted and considered by all partners. Proposed actions are summarised below and page 18 of appendix A also addresses actions that are already underway to address the issues identified below:

1.      Support national efforts to improve CDOP and child mortality registration (see national recommendations in appendix A: Figure 15)

2.       Reduce infant mortality in Bradford District through a coordinated response to reduce modifiable risk factors, specifically:

a.   Sudden Unexpected Deaths in Infants (SUDI) and unsafe sleeping arrangements

b.   Substance misuse / alcohol misuse by parents

c.    Parental mental health issues

d.   Genetic risk associated with consanguinity

e.    Parental Smoking

3.      Monitor child deaths that occur as a direct or indirect result of Covid-19 and make appropriate recommendations for action to Bradford District COVID Outbreak control board.

4.     Ensure safe swimming campaign messages are shared with the Living Well Schools programme ahead of summer and pro-actively ahead of predicted heat waves.

5.      To seek assurance that partners are working collectively on the suicide prevention agenda (and that bereavement support services are available to Children, Young People, and Families)

6.      Support efforts to reduce and mitigate against poverty and associated factors (domestic abuse, mental health, crime, poor and overcrowded housing, homelessness, access to services and benefits)

7.           Further analysis to be undertaken to help understand specific demographic details, and to target intervention and communications and campaign accordingly.

8.      Share the CDOP annual report findings and recommendations with strategic partnerships (Bradford District Well-Being Board, newly established Children and Young People & Family Partnership, and Children’s Safeguarding Board)

Action: Director of Public Health