A presentation of the Herefordshire and Worcestershire Child Death Overview Panel’s (CDOP) Annual Report for 2021-2022.

Elizabeth Altay provided an overview of the Child Death Overview Panel Annual Report 2021-22. The report was written by Herefordshire and Worcestershire Child Death Overview Panel (CDOP) and notes any thematic learning and actions that can be utilised to prevent future child deaths. The principal points included:

1. In the year 2021-22, there was a total of 43 child death notifications and 28 were reviewed by the panel.
2. Of those 28 cases, 67% were ‘expected’ deaths whereas 33% were ‘unexpected’ and triggered a joint agency response.
3. The purpose of the panel is to look at any modifiable factors and CDOP identified modifiable factors in 57% of the cases reviewed.
4. The most commonly modifiable factors identified were smoking and neonatal care.
5. There are four themes that presented more frequently than others during child death reviews. These are:
   1. 1. Prematurity

                                               i.     10 of the 28 deaths reviewed were children who were born prematurely.

                                               i.     7 of the 28 deaths reviewed identified smoking as a modifiable factor.

                                               i.     5 of the 28 deaths reviewed identified neonatal care as a modifiable factor.

                                               i.     8 of the 28 deaths reviewed identified families with complex social factors as a modifiable factor.

6. Page 14 of the report focuses on the recommendations from the previous annual report and highlights the progress against those recommendations.

The Managing Director of Wye Valley NHS Trust asked whether lack of access to higher levels of neonatal care (level 2 and 3) was an issue regarding child deaths, which is not provided in Herefordshire, or whether it was a deficit of level 1 neonatal care, which is provided in the county.

Elizabeth Altay noted that the quality of neonatal care, whether provided in Herefordshire or Worcestershire, is not drawn out in terms of geography in the report and instead is more general. Each individual case would have looked at access to care and any recommendations about access to care would have come out of the individual child death review which would then have been taken forward to the Local Maternity and Neonatal System (LMNS).

The Director of Public Health asked whether data could be combined from previous years to see if there are any trends/commonalties in terms of any themes that may be present.

Elizabeth Altay accepted that this was a useful recommendation and the CDOP would look to take this forward.

The board therefore agreed to the suggested recommendation to combine data from previous years going forward in order to identify new trends and emerging issues.

The recommendations were proposed, seconded, and approved unanimously.

Resolved:

a)    That the Board consider and note the report.

b)    That data is combined from previous years going forward in order to identify new trends and emerging issues.