Agenda item

This annual report is provided by the Child Death Overview Panel (CDOP) for the Brent Local Safeguarding Children Board (LSCB). The report analyses Sudden Unexpected Deaths in Infancy since the commencement of the CDOP process in 2008. The importance of safe sleeping practices is highlighted.

Dr Melanie Smith (Director of Public Health, Brent Council) introduced the report which analysed the Sudden Unexpected Deaths in Infancy (SUDI) since the commencement of the Child Death Overview Panel (CDOP) processes in 2008. She encouraged members of the board to consider how they could assist in promoting awareness of the need for infant safe sleeping in order to prevent accidents.

Dr Arlene Boroda (Designated Doctor for Unexpected Child Deaths, Brent Clinical Commissioning Group) added that the annual report had been brought to the Health and Wellbeing Board in order to spread the findings more widely. She said that there was a desire to develop a more holistic approach to tackling these problems and to link CDOP processes to other relevant organisations. She also drew Members’ attention to the case studies within the report which detailed where a coroner had issued a ‘Rule 28’ (which provided coroners with the duty to make reports to a person, organisation, local authority, government department or agency where the coroner believed that action should be taken to prevent future deaths). She noted that it was important for all of the information and lessons learnt from Rule 28 cases, to be collated and disseminated effectively.

The Chair referenced paragraph 1.7 of the covering report and questioned whether the child death reviews spanned across different years, rather than solely looking at the deaths notified in 2016-2017. Dr Smith stated this was correct and that the reviews were not all from cases of the same year of notification. Dr Boroda added that time lags had often been caused because of the need to follow due process, particularly when coroner’s inquests or police investigations needed to be completed before the review could begin.

(Dr Ethie Kong and Dr Sarah Basham joined the meeting at 7.08pm)

Questions were also raised on the steps which were being taken on a national level to address this issue, and whether there were any notable recent upwards or downwards trends on SUDI notifications within the findings. Dr Boroda stated that the Department of Education (DfE) were presently collating the statistics from across the country in this area and that the Department of Health (DH) would be taking over this function in the future. She also noted that at a London level Brent CDOP and Brent Local Children’s Safeguarding Board (LSCB) had engaged with the Healthy London Partnership and different voluntary agencies in order to network and ensure that the lessons learnt had been shared extensively. On trends, Dr Smith outlined that the total number of reported child deaths in Brent were largely on a downwards trend, but this could unfortunately change year-on-year. Dr Boroda stated that there also needed to be a focus on vulnerable adolescents in order to avoid preventable deaths in areas such as knife crime, road traffic accidents and gun crime. 

Additional questioning arose on the statistics within the report, which included why St Mary’s Hospital was the location with the highest number of recorded deaths, and why there appeared to be a high proportion of child deaths from Eastern European or Romanian ethnicities. Dr Boroda explained that St Mary’s Hospital had an intensive care and trauma unit for children which could be attributed in part as to why the more deaths were recorded there. Dr Smith commented that health visiting centres had highlighted an emerging trend of Eastern European families with risk factors which related to SUDI, however she said that the overall reason for the high proportion of child deaths was not clear. She added that dedicated practitioners with translation skills across health and care settings would be beneficial to better understand these trends.

Dr Smith also outlined to the Board that an additional focus of Brent CDOP was on maternal health and the different risk factors (such as body-mass index, obesity, vitamin uptakes) which were thought to be associated with sudden unexpected child deaths. It was agreed that report which specifically considered maternity data and its possible correlation with unexpected child deaths be produced for consideration at a future meeting of the Health and Wellbeing Board. It was noted that this would need to be a closely collaborative piece of research between both the Council and Brent Clinical Commissioning Group (CCG), and that assistance with Healthwatch Brent would also be needed to assist with any community outreach work arising from this.    

It was RESOLVED that:

(i)         The Brent CDOP Annual Report be noted;

(ii)        A report be produced by Officers which assessed the underlying causes of why there had been a higher proportion of Eastern European and Romanian child deaths;

(iii)       A report be produced by Officers which assessed the maternity data from child death cases and whether there were any notable trends on early or late maternity or attendance at antenatal classes, and an analysis of how Brent’s annual child death notifications compared to LSCBs in the Home Counties; and

(iv)       In connection with resolution (iii), the Chair would write to any local NHS Trusts who refused to provide maternity data, to encourage them to do so in order to form part of the research; and

(v)        Healthwatch Brent would assist with any community outreach work to raise awareness of SUDI in the borough.