Agenda item

The Board received the 2020/21 Annual Report of the Oldham, Rochdale and Bury (ORB) Child Death Overview Panel (CDOP) presenting the annual review of CDOP data for ORB. The CDOP reviews all child deaths under 18 years, but not including still births, late foetal loss or termination of pregnancy. The Panel do not determine the cause of death but instead explores all the factors surrounding the death of the child. This learning enables required actions to be taken to protect the welfare of children and prevent future deaths.

Each CDOP collates information on the cases that have been closed in the last 12 months in order to review for themes. This enables each area to identify any lessons learnt and recognise where population level interventions are required to reduce future child deaths. The ORB CDOP report is supported by a Greater Manchester (GM) report which gives an overview of patterns across all four CDOPs in GM which, in view of the relatively small numbers, and consequent difficulties with data analysis, can be helpful when analysing themes.  The Annual Report presented an analysis of data gathered and presented recommendations and actions arising from considerations in the previous year.

The Annual Report was supported at the meeting by a presentation introduced by Rebecca Fletcher, Consultant in Public Health and Chair of the ORB CDOP for 2020/21.  The Report reviewed the deaths of all children who had died in the ORB areas, with data collected in the period 1^st April 2020 – 31^st March 2021.  47 cases had been notified, of which reviews had been completed in respect of 29 cases.  Noting reported data that Oldham had the highest infant and child mortality rates per 100,000 births by local authority in the period 2018-20, the Board considered the causes of death in closed cases, demographic data, and modifiable factors that were related to deaths across ORB.  A number of actions had been identified in the Annual Report to look to change services to address the issues arising, it being key for all services to respond to and learn from child deaths.

While a request was made for sight of Oldham specific data, comment was made that it was sad overall to see causal factors, such as smoking and obesity arising, all of which were addressable.  The need for the Board to focus on what is and needs to be done to address issues was therefore stressed.  A reflection on the difficult conversations that would be needed with particular communities around genetic conditions was noted, as was a need to consider a non-traditional approach to engage with these communities which, it was suggested, might take the form of grass roots work, possibly through a micro-commissioned piece of work. The Board was advised of a small genetic outreach service provided in the past year where there was much that could be enhanced. 

The Board considered the need for services to link up, noting that various service providers were likely to come into contact with families at risk and staff might need training to recognise warning signs; noted the need for an Oldham specific solution, there being linkages between factors linked to child death rates such as, for example, housing, life expectancy and more generally to the range of identified health inequalities; noted that the people described in the Annual Report were those not likely to get their voices heard and how to address this needed consideration; and considered how to ensure access to those  services which addressed the modifiable factors.

While noting that work was underway in a number of organisations and locations to address issues highlighted, the dangers of silo working was flagged and the need for a joined up approach to address child mortality issues was accepted by the Board.  A Greater Manchester (GM) dimension was noted and a request made for those with links into GM structures to identify and flag up those issues which impacted across the region, with issues around translation services being highlighted.  Other issues were noted where further detail might be required, particularly including parental age at the time of child death and getting a better understanding of issues related to the deaths of those under 17 years of age.

While noting the work ongoing to address the issues highlighted in the Annual Report, the concern of the Board was such that an approach to ensure all pieces of work necessary were drawn together was considered of importance.  To this end it was proposed that a mini-action plan could be developed, with all services and organisations providing feedback so that actions could be seen.

RESOLVED – That

1.    the 2020/21 Annual Report of the Oldham, Rochdale and Bury Child Death Overview Panel be noted;

2.    the continuing work to address infant mortality in Oldham, as outlined at Section 5 to the Annual Report, be agreed;

3.    a further report, presenting further information in relation to child mortality factors in Oldham and an action plan addressing issues of Child Mortality in Oldham to ensure that actions are joined up, be submitted to the next meeting of the Board.