Child Death Annual Report Overview in North East London Boroughs
This report presents data and insights from the Child Death Overview Panel (CDOP) for the boroughs of Waltham Forest, Tower Hamlets, Newham, City, and Hackney in North East London. It covers the period from April 2021 to March 2022, highlighting notifications and reviews of child deaths, modifiable factors, and actions taken. The purpose of CDOP is to identify preventable factors in child deaths and support families through the process, in line with statutory responsibilities. The report emphasizes the importance of learning from these reviews to prevent future tragedies and improve child welfare.
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CDOP Waltham Forest, Tower Hamlets, Newham, City and Hackney CHILD DEATH ANNUAL REPORT Child Death Overview Panel (CDOP ) on behalf of the boroughs of Newham, City & Hackney, Waltham Forest and Tower Hamlets. April 2021- March 2022 Nicola Needham CDOP Manager Acknowledgments to Bella Lowen Deputy CDOP Manager Lynne Kitson Public Health Team Principal Analyst Newham
This report will include information and data from across 5 boroughs in North East London (NEL), Newham, City & Hackney, Tower Hamlets and Waltham Forest (Known as WELC during this period. ) 1. Background to CDOP and context of one single CDOP across 5 Boroughs 3-7 2. Reported child deaths notifications between April 2021 and March 2022 8-17. 3. Reviewed child deaths between April 1 2021 and March 31 2022. 18-22 Slides Slides Slides 4. Modifiable Factors and Learning and Actions from the Reviews. 23-28 Slides Note* for the purpose of child death reviews and given that there are very few deaths in the City of London , City has been included with Hackney child death data since reviews began.
Purpose of CDOP To review each child death and to identify any modifiable or preventable factors that might have prevented the child death and share this learning. To ensure support for families through the process. CDOPs in England have been reviewing child deaths since becoming mandated in 2006 with the establishment of Local Safeguarding Children s Boards (LSCB) in every Local Authority in England. Department for Education (DfES) publication, Every Child Matters Guidance, Working Together to Safeguard Children Chapter 5 (2018)* Every CDOP to meet regularly to review child deaths chaired by an appropriate Public Health Professional with a membership based on multi agency professionals in attendance. Statutory responsibility for Local Authorities since the 2004 Children s Act. 2018 Child Death Reviews and CDOP became a joint statutory responsibility for Local Authorities and the NHS (* National Child Death Statutory Guidance 2018 ) 2019 the National Child Mortality Database began collecting child death data and all new notifications are expected to be registered to the database within 48 hours of receiving the local notification. This is the responsibility of each CDOP. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/859302/child -death-review-statutory-and-operational-guidance-england.pdf https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/942454/Working_together_to_safeguard_children_inter_agen cy_guidance.pdf
The National Child Mortality Database (NCMD) Notifications of new deaths are submitted to each individual CDOP and shared onto the NCMD in real time via eCDOP case management system since 2017. Learning from CDOP is shared nationally though the National Child Mortality Database via digital case management system eCDOP The NCMD gather and analyse information on all children who die in England, to improve and save children s lives in the future. In the last year they have produced important studies examining Child Mortality and Social Deprivation and Suicide in Children and Young People https://www.ncmd.info/
Background and Context of CDOP and Child Death Review Hub Newham, Tower Hamlets, Waltham Forest, City & Hackney 2016 - Alan Wood Review and Report recommendation for larger CDOPs in England. July 2018 transfer of accountability from Local Authorities to joint with NHS England and Local Authority November 2019 merging of Newham, Tower Hamlets, Waltham Forest and City & Hackney onto one eCDOP electronic data management system December 2019 Agreement in principle for Boroughs to join. March 2020 Newham Council agreed to host CDOP /CDR Hub. Legal Agreement in place March 2020 Covid suspension of any formal processing of CDR Hub. Informal join up in progress. July 2021 Tender for Family Liaison Coordinators completed. October 2021 Legal Agreement between 5 boroughs and CCG was formalised and completed. December 2021 January 2022 recruitment of two part time family liaison coordinators. February 2021 Family Liaison Coordinators in post. 31 March 2022 completion of Tupe of Deputy Manager from Waltham Forest into Deputy Manager Post in Newham. Recruitment of Coordinators into the Hub in progress. Map to show the geographical context of WELC in relation to North East London and neighbouring Barking & Dagenham Havering Redbridge CDR Team (BHR)
Over arching CDOP Newham, Waltham Forest, Tower Hamlets, Hackney & City Child Death Review Hub Manager/Lead CDR Co-ordinator 3 CDR Co-ordinators ( inc Deputy Hub Manager) 1 FTE Key worker (Voluntary Sector) Lead Local Authority London Borough of Newham Designated Child Death Doctors 4 within this system Local CDR meetings Local CDR meetings Neonates & Mortality meetings Neonates & Mortality meetings JARs JARs Multi-agency attendance at all these meetings Homerton: primary*, secondary & tertiary care Barts Health: primary*, secondary & tertiary care Child deaths not requiring JAR or neonate/mortality meetings Child deaths not requiring JAR or neonate/mortality meetings
Structure Chart for Child Death Review Hub based in Newham 2022 Child Death Review Hub Manager Nicola Needham Deputy Child Death Review Hub Manager Child death Review Coordinator Child Death Review Coordinator Bella Lowen Phyllis Paca Khansa Khan Family Liaison Coordinators 1 WTE Child Bereavment UK Suzette Mondroit Sophie Pilail
April 1 2021- 31 March 2022 Overall the total number of new child death notifications was 85 Borough 2020- 21 2021- 22 Number of Child Deaths per Borough 2021-22 Total 85 Number of Child Deaths per Borough 2020-21 Total 96 35 35 30 30 Newham 31 31 25 25 City Hackney 22 18 20 20 15 15 Waltham Forest 24 17 10 10 5 5 0 0 Newham City & Hackney Waltham Forest Tower hamlets Newham City & Hackney Waltham Forest Tower hamlets Tower Hamlets 19 19 The overall number of child deaths across this area is less than the previous year. The boroughs of Newham and Tower Hamlets have remained the same. There were less deaths in the borough of City Hackney and Waltham Forest than in the previous year. Total over 2 years = 181 TOTALS 96 85
Child death notifications, reviews and cases carried over comparing 2021 Child death notifications, reviews and cases carried over comparing 2021- -22 & 2020 22 & 2020- -21 21 In 2021-22 there were 15 less death notifications than the previous year. There were 35 more cases reviewed over 9 CDOPs in 2021-22. There were 15 less cases carried over than the previous year where there were 141 outstanding cases as of 31 March 2021 compared to 126 as of 31 March 2022 Source : CDOP data ecdop Shows cases reviewed in by borough and year of death 2020-21 shows total cases reviewed by borough and year of death 2021-22 Review ed 2020-21 CH N TH WF Total Tota l 2016/17 2017/18 2018/19 2019/20 2020/21 2021-22 Total 1 1 2 2020-21 CH N TH WF 0 CH N TH WF Total 0 5 17 38 5 65 Death notificati 2016/17 2 2 4 1 2017/18 4 10 8 5 27 24 31 19 22 96 ons 2 3 12 3 2018/19 20 18 7 15 60 10 17 2 22 8 3 Reviews 12 22 16 12 65 2019/20 2 5 2 9 2020/21 c/o to 2021-22 12 19 12 Total 26 33 16 25 100 30 41 40 30 141
Numbers of child deaths comparing expected with unexpected Numbers of child deaths comparing expected with unexpected 2021 2021- -22 22 Unexpected v Expected Child Deaths 2021-22 Expected Unexpected Unexpected deaths are those that occur where within the previous 24 hours death was not expected. Overall in 2021-22 there were only slightly more expected child deaths than unexpected. Newham had only slightly more expected cases than unexpected compared to the year 2020-21. For all other Boroughs, Tower Hamlets had more expected deaths in 2020-21 whilst Waltham Forest and City & Hackney were about similar in the previous year. Just under half of all deaths in 2021-22 were not expected. In all deaths the majority were in the age group under 28 days old. It will be important to monitor this in the coming year. Source : CDOP data ecdop
Total number of child deaths across 4 Boroughs in in the previous 4 years Borough 2018-19 2021-22 31 2019-20 2020-21 Newham 39 30 31 18 City Hackney 14 26 24 17 Waltham Forest 32 18 22 19 Tower Hamlets 28 23 19 85 TOTALS 113 97 96 Number of chid deaths between 2018 and 2022 per borough Since 2018 all Boroughs have shown an overall decline in the number of child deaths. In 2020-21 during the pandemic it was reported nationally that the number of child deaths was lower than compared to previous years and may have been the lowest on record. In our area 2021-22 shows another decline. https://www.ncmd.info/publications/child-mortality- pandemic/ Source : CDOP data ecdop 45 40 35 30 25 20 15 10 5 0 2018-19 2019-20 2020-21 2021-22 Newham City & Hackney Waltham Forest Tower Hamlets
Table showing the percentage of the child notifications in 2021-22 by age groups in each borough compared to the national England average for the years 2020-21 & 2021-22 . In 2021-22 notifications , Newham, City & Hackney and Waltham Forest has higher than England average deaths in the under 28 days and 28 day to 1 year age whilst Tower Hamlets had significantly less deaths in the 28 1 year age group. Tower hamlets had higher than National average in 1-4 and 15-17 age group. City & Hackney have a higher percentage of child deaths in the 5-9 year age group than the England average. Newham and Tower Hamlets have higher than the English National average in the 10-14 year age group. 28-364 days 1-4 Years 5-9 Years 10-14 Years 15-17 Years 0-27 days 46% 18% 11% 5% 9% 12% England Average 2021-22 45% 20% 9% 6% 9% 11% England Average 2020-21 44% 27% 6% 11% 6% 6% Hackney City Newham 32% 33% 10% 6% 13% 6% 47% 5% 16% 5% 11% 16% Tower Hamlets Waltham Forest 53% 24% 18% 0 0 6% 45% 20% 13% 6% 8% 7% Average all Boroughs In all boroughs combined the percentage of deaths in all age groups is similar to the national England average except in the age groups 1-4 years where the percentage is slightly higher and in 15-17 year age group where the percentage is lower than the England average. Source : CDOP data ecdop and NCMD
Child Mortality Rates age 1-17 years 2017-2019 England Average 10.8 North West Region 12.6 London Region 10.6 South West Region Infant Mortality Rates 0-1 year 2020/21 8.9 England Average 3.9 4.1 (5th highest in London) Newham 3.6 (9th highest in London) Hackney/City 3.4 (11th highest in London) Waltham Forest 3.3 (12th highest in London) Tower Hamlets Newham is higher than the national average and higher than the London Region rate at 3.4. Newham has the highest infant mortality rate in North East London. The London region as a whole is lower than the England average, compared to highest which is West Midlands Region at 5.6 Source: Office for National Statistics (ONS) Child and Maternal Health - OHID (phe.org.uk)
Rate of Child deaths ages 0 Rate of Child deaths ages 0- -17 inclusive 17 inclusive Number of reported child deaths all ages 0-17 between 2018-22 Rates of Child Deaths per borough and overall 2019-2022 The blue line indicates the overall rate of child deaths for all boroughs in the age group 0-17 years. 0-17 inclusive counts Borough Newham City Hackney Waltham Forest Tower Hamlets TOTALS 2018-19 39 14 32 28 113 2019-20 30 26 18 23 97 2020-21 31 24 22 19 96 2021-22 31 18 17 19 85 Child deaths - 0- 17 years inclusive 2019-2022 45.0 Child deaths - 0- 17 years inclusive 2018-2022 40.0 50.0 45.0 35.0 40.0 Crude rate per 100,000 30.0 Crude rate per 100,000 35.0 25.0 30.0 20.0 25.0 20.0 15.0 15.0 10.0 10.0 5.0 5.0 0.0 Newham City & Hackney Waltham Forest 0.0 2019-20 2020-21 2021-22 2018-19 2019-20 2020-21 City & Hackney 2021-22 Tower Hamlets Overall Newham Source : CDOP data ecdop Public health profiles - OHID (phe.org.uk)
Child death rate ages 1 Child death rate ages 1- -17 years inclusive by borough 17 years inclusive by borough Numbers of child deaths reported by year in the 1-17 age group Child death rates 1-17 years old inclusive Borough 2019-20 2020-21 2021-22 20.0 Newham City Hackney <10 11 11 <10 11 <10 <10 18.0 16.0 Waltham Forest <10 <10 Crude rate per 100,000 14.0 Tower Hamlets <10 <10 <10 12.0 TOTALS 36 24 29 10.0 Rates of child deaths by year per borough 8.0 Borough 2019-20 2020-21 2021-22 6.0 Newham 9.6 13.1 13.0 4.0 City & Hackney 17.8 9.6 8.0 2.0 Waltham Forest 13.8 6.1 6.0 0.0 2019-20 2020-21 2021-22 Tower Hamlets 12.0 4.4 13.2 Newham City & Hackney Waltham Forest Tower Hamlets Overall National Average Overall 13.0 8.6 10.3 The National data shows that in the age 1-17 year group 2018- 2020 England average child death rate was 10.3per 100,000. The total child death rate in this area is below the England average. The graph shows that Newham continues to have an above average rate of child deaths in this age group. In 2020 Tower Hamlets shows a steep increase in child death rate in this age group. City Hackney shows a decrease in the child death rate for this age group in 2020. National and Local data reference Source : Public health profiles - OHID (phe.org.uk)
Child death notifications by Age 0-1 year comparing years 2020-21 2021-22 Borough Babies under the age of 1 2020-21 2021-22 Percentage of total child death under 1 year 2021-22 Newham 73% 64% City Hackney 72% 68% Tower Hamlets 80% 52% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Waltham Forest 82% 77% Newham City Hackney Tower Hamlets Waltham Forest National National 65% 64% Child deaths numbers and rates fluctuate a little year on year. In 2020-21, all boroughs showed a higher than the National average child deaths in under 1 year age. In 2021-22 there was little change except in Tower Hamlets where there was a significant decrease to 52% in the overall child deaths in age group under 1 year. Majority of these cases were in 0-28 days age group neonatal period. Percentage of total child death under 1 year 2020-21 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Newham City Hackney Tower Hamlets Waltham Forest National Source : National Child Mortality Database data 2020- 21 & 2021-22 eCDOP
0 0- -17 years child Population by ethnicity by borough 17 years child Population by ethnicity by borough 0-17 population by ethnicity and borough, 2020/21 60% 50% 40% 30% 20% 10% 0% Asian Black Mixed Other White City & Hackney Newham Tower Hamlets Waltham Forest Tower Hamlets has the highest Asian population of the boroughs with Newham close behind. All boroughs have similar black population except Tower Hamlets where there are less black children living. Mixed and other groups are fairly similar. Newham has the highest non white ethnic population of the four boroughs where Waltham Forest has the lowest. Public health profiles - OHID (phe.org.uk)
Total Child Death Reviews completed at CDOP 2021 Total Child Death Reviews completed at CDOP 2021- -22 22 100 cases were reviewed included deaths that occurred in 2016-17, 2018-19, 2019-20, 2020-21 and 2021-22. The pattern of child deaths reviews does not provide any data relating to trends as these reviews include deaths from previous years which have taken time to be ready for CDOP. These reviews provide data relating to learning and identifying modifiable factors. 9 scheduled CDOP meetings took place between 1 April 2021 and 31 March 2022, 1 was cancelled due to unforeseen circumstances. 5 Neonatal case panels and 4 older children panels took place In all areas other than perinatal ( nenoanatal) or chromosomal genetic categories there were less than 10 deaths reviewed. Reviewed Deaths by Category of death 2021-22 Trauma 0 Suicide 0 SUDI/SUDIC 0 Perinatal 37 Malignancy 0 . . Infection 0 Deliberately inflicted harm 0 Chronic Medical 0 Chromosomal 25 Acute Medical 0 0 5 10 15 20 25 30 35 40 Source : eCDOP CDOP Data sets and records
Child Death Reviews completed by Age with modifiable factors. Child Death Reviews completed by Age with modifiable factors. Modifiable Factors identified by age group 29 out of 100 (29%) deaths reviewed had modifiable factors almost 1/3 England Average of deaths 37% 18 16 14 12 10 8 Majority of modifiable factors were identified in age under 28 days. 6 4 2 0 There were more modifiable factors in the older child age group 15-17 years Age under 28 days y 1 Age 29-364 days TOTAL Age UNDER 1 year Age 1-4 years Age 5-9 years Age 10-14 years Agre 15-17 years TOTAL Age 1-17 years inc Modifiable Factors by Age Where there were less than 10 deaths in age groups the numbers have been omitted. The chart shows cases where modifiable factors were identified. Last years reviews showed children under 28 days to have the highest number of modifiable factors with children in age group 15-17 years next. There were less than 10 child deaths reviewed individual age groups between 1 and 17 and were less modifiable factors in age group above 1 year. This may be because children in this age group tend to fall into medical category such as cancer chromosomal or complex medical condition. There tends to be more unexpected deaths in children in the under 1 year age group and in the 15-17 year age group which may account for the possibility of more preventable factors being identified. Source : eCDOP CDOP Data sets and records National Child Mortality Database
REVIEWED Child deaths in 2021-22 place of death Chart showing place where death occurred or incident that led to death Hospital Home/Other residence 6% 2% Labour Ward 27% Neonatal Unit 31% other including public places and abroad 17% 17% Unknown Almost 80% of child deaths reviewed in 2021-22 occurred in hospital setting. Just over 20% occurred in places other than hospitals including at home or in a public place. This suggests that of the cases reviewed majority was to children already in a hospital setting who most likely had a serious medical condition. Around 30% of hospital deaths occurred either soon after birth due to extreme prematurity or within 28 days of being born in most cases due to prematurity or chromosomal condition. Source : eCDOP CDOP Data sets and records
Number and percentage of Cases Reviewed with modifiable factors by borough and overall 2020-21 2021- & 2022 Borough 2020-21 England average 34% 2021-22 England Average 37% City Hackney 12 cases of which 17% had modifiable factors 26 of which 31% had modifiable factors Newham 20 cases of which 25% had modifiable factors 33 cases of which 37% had modifiable factors Tower Hamlets 15 cases of which 20% had modifiable factors 16 cases of which 19% had modifiable factors Waltham Forest 12 cases reviewed of which 33% had modifiable factors 25 cases reviewed of which 52% had modifiable factors AVERAGE across all Boroughs 23.75% 34.75% This shows an increase in the number of modifiable factors identified between 2022-21 and 2021-22 for almost all boroughs. The average for all boroughs sits just below the England average at 54.75% for the last year. Waltham Forest however has identified modifiable factors close to the England average in 2020-21 and significantly higher in 2021-22. Source : eCDOP CDOP Data sets and records
Modifiable Factors in each borough and which category they were identified 2021-22 A Total of 34.75% of 85 cases reviewed had modifiable factors with some cases identifying more than one modifiable factor. HACkNEY & CITY Cases were reviwed in each area category except trauma and medical. Modifiable factors identified in cases of trauma, SUDI, perinatal and chronic medical consition. NEWHAM Reviewed cases in all categories except SUDI and Trauma. Modifiable factors were identified in all areas except malignancy, chromosomal and chronic medical condition Modifiable factors and in categories TOWER HAMLETS Majority of cases reviewed in this year medical, perinatal and chronic medical. Modifiable factiors identified in perinatal cases, acute medical, WALTHAM FOREST Identified modifiable factors in cases of trauma, medical surgical events, perinatal events, chromosomal or genetics, sepsis, and trauma
Modifiable Factors Learning Outcome/Actions Ages Under 1 year. Modifiable Factors Learning Outcome/Actions Ages Under 1 year. Failure to diagnose sepsis Issue around how care is planned when there is no ante natal diagnosis of babies with conditions that are incompatible with life or not likely to survive. Late diagnosis will not change the outcome but may prepare parents better in trms of choices after the baby is born. Failure to diagnose uterine rupture in mother due to abdominal palpation not taking place Failure to diagnose Breech Failure to diagnose hypoglycaemia ( low blood sugar in baby) OUTCOMES * baby deaths in the neonatal period with any learning are fed back to maternity units. These cases are reviewed in conjunction with serious incident reviews and cases where using the perinatal mortality review tool (PMRT) is applied as well as Inquests and Maternity Healthcare Safety Investigation Branch (HSIB). CDOP seeks assurance that any changes to practice have been instigated through the Local maternity Systems Networks. CDOP and will be systematically presenting findings to the Maternity Neonatal Networks at the Integrated Care Board In some cases parents felt that they were not being listened to which may have led to a delay in care planning and might have therefore had a different outcome. In some cases mothers did not adhere to care. In some cases where there were sudden unexpected deaths is infants (SUDI) modifiable factors such as unsafe sleeping practices and smoking in the household were identified Sometimes congenital conditions are due to genetic factors because parents are related. Cultural issues may have impacted on the care and outcome in some cases.
Modifiable Factors Learning Outcome/Actions Ages 1 Modifiable Factors Learning Outcome/Actions Ages 1 - - 4 years 4 years Window safety preventing falls Co sleepimg is a modifiable factors in some SUDI cases . Delays in obtaining treatments in NNU could make a difference to the outcome in some cases Learming around how safe sleeping messgaes are communicated especially to fathers who may not always be present when safe sleeping practices are discussed with professionals 1. Reviewed safety and raised awareness across all boroughs Raised awareness around safe sleeping and Hackney ICS undertaking report around SUDI awareness Review of Care of the Next Infant policy (CONI) and awareness across agencies taking place in Newham
Modifiable Factors Learning Modifiable Factors Learning Outcome/Actions under 5 Outcome/Actions under 5- -9 and 10 9 and 10- -14 years 14 years Communication issues between agencies, hospitals and Local Authorites GPs are not always informed and do not always receive detailed records when transferring from one GP to another. Child with asthma died after collapsing in school. Case was a Serious case Review and went went to Inquest. The Coroner provided 5 future death reports under Regulation 28 of Coroners Act (see next slide) The issues identified must be responded to the Coroners. Hospital paediatricians are not able to see relevant records if a child is treated at a different hospital. https://www.england.nhs.uk/wp-content/uploads/2019/10/Reg_28_Process_-_redacted.pdf Hospital paediatricians do not have access to all social care records Internal review requested in CAMHS Important to understand mothers mental health conditions CAMHS. Covid may have impacted in some cases where families were fearful of attending hospital for appointments Did not attend policy was not in place and might have made a difference to the outcome. Rapid Review and actions for Schools in Tower Hamlets shared across all boroughs for learning Awareness of impact of COVID and fear of attending hospital to be considered
Child with asthma died after collapsing in school. Case had a rapid review and was an Inquest case. The Coroner provided 5 Prevention of Future Death Reports under section 28 . Coroners PFD directive for 5 agencies: For Bart's Health Trust/ GP/Allergy services: 1.Discrepancy between respiratory physician and GP assessment of Asthma severity.. There must be a way of identifying a child in his position. 2. Inappropriate Asthma inhaler available in school. Appropriate inhaler should have been accompanied by a spacer for best administration. 3. Must ensure school health care plan is accurate and up to date, and identical copies stored at home, school, the GP surgery and hospital records. 4. School plan should highlight correct and potentially lifesaving use the EpiPen and to use it immediately. For School: to address matter of concerns to prevent future deaths- reinforcing first aid training for staff For Chief Medical Officer: consideration of availability of generic adrenaline auto-injectors in same way as defibrillators, in public spaces For School Nursing services: focussing on role of school nurses in education health plans (EHP) For London Ambulance Service : consider use of intramuscular EpiPen auto injectors in emergencies with respiratory compromise, loss of consciousness, or if in doubt - potentially life saving with minimal harm
Modifiable Factors Learning Outcome/Actions 15-17 years Deaths due to youth exploitation/gang affiliated crime show factors associated with gangs, known to police, known domestic abuse in household , known to be around older perpetrators of crime and known to social care. A joined up approach to care , good communication and sharing of information might have made a difference Suicide Housing mental health Possible impact of covid/isolation communication between agencies. i Learning reviews were carried out for suicide case and the case of murder within gangs. This was offered widely across agencies within Newham . Influenced the Public Health Suicide policy within Newham and learning shared across boroughs. caffeine energy drinks used to keep alert for late online video gaming may be a factor Coroners were asked to include this in their investigations of similar cases
