Child Death Overview Panel Annual Report

Executive Summary

The Leeds CDOP has been undertaking its role to review the death of every child aged under 18 resident in the city since April 2008.

During 2018, new national guidance was issued regarding both safeguarding arrangements and CDOP processes. National leadership for the child death review process was transferred from the Department for Education to the Department of Health and Social Care in July 2018. Chapter 5 of Working Together to Safeguard Children (2018) contains a framework for the two statutory child death review partners (the Local Authority and the CCG) to make arrangements to review the deaths of children.

In October 2018 the, “Child Death Review: Statutory and Operational Guidance (England)” was issued. This detailed guidance combines best practice with statutory requirements that must be followed. By setting out key features of the process, it aims to standardise the outputs of the child death review process, thereby enabling thematic learning. However, child death review partners are able to make arrangements as they see fit in order to meet the statutory requirements under the Children Act 2004. The implementation date for the new arrangements was September 2019.

During 2019-20 (the period covered by this report) the current Leeds CDOP has continued to function as previously. It comprises of two separate Panels, a Neonatal Panel and an Older Children Panel, which each bring together appropriate experts from a range of sectors (Appendix 1). Both Panels were chaired by the Deputy Director of Public Health, Dr Sharon Yellin, until her retirement in April 2020. In the year 2019-20, the CDOP met on 12 occasions (4 Neonatal Panels, 8 Older Children Panels) and reviewed 79 deaths (46 neonatal cases and 33 older cases)

There were 59 reported deaths in 2019-20 of Leeds resident children aged under 18 years old, a slightly higher figure than the previous year, when there were 57 deaths. However it is not possible to discern a clear trend. The pattern fluctuates, varying from a high of 71 deaths in 2009-10 to a low of 41 deaths in 2013-14. The key findings below show the deaths reviewed by the CDOP during 2019-20 and, to allow more context, also includes deaths reviewed prior to this period.

For 2019-20, key findings in relation to neonatal deaths include:

  • From 2008 the predominant categories of death were ‘Perinatal/neonatal event’
  • (69%) and ‘Chromosomal, genetic and congenital anomalies’ (29%).
  • Smoking continues to be a profound risk factor for neonatal death. The rate of
  • maternal smoking identified in cases reviewed in 2019-20 was 28%.
  • Consanguinity was identified in 11% of all neonatal deaths reviewed in 2019-20 (6% over all years).


Since 2012 onwards:

  • There was over-representation of mothers and babies from ethnic backgrounds other than White British. This was most marked for women of Asian Pakistani backgrounds, but was also a feature for mothers and babies of Black African backgrounds. This pattern has been noted in previous CDOP annual reports, and appears to be a persistent pattern, which fits with the national picture. In the 2016-17 CDOP annual report, a specific analysis of CDOP data for ethnicity was included which highlighted high parity and high body mass index (BMI) as prominent risk factors for women of Asian backgrounds; and late booking and high BMI as prominent risk factors for women of African and Caribbean backgrounds.
  • Cousin marriage increases the risk of a birth disorder (6%) compared to unrelated couples (3%), and most of this increase is linked to genetic conditions which may cause death or long term disability. Since 2012, 5% of all neonatal deaths were from inherited conditions linked to cousin marriage. In most of these cases, there was no known history of genetic conditions in the family prior to the death of the baby, so they were not amenable to prevention via timely genetic counselling. The majority were therefore classified as having no modifiable factors present. 
  • Early booking for maternity care (before the 12th completed week of pregnancy) is considered a quality standard, and women booking later are likely to be at higher risk. In 2019-20, 7% of cases reviewed featured late booking. In the cohort of women experiencing neonatal deaths since 2012, 9% booked late. The 2016-17 analysis of CDOP data by ethnic group showed that women of African and Caribbean backgrounds were much more likely to book later. 
  • Smoking is a profound risk factor for neonatal death. The rate of maternal smoking identified in cases reviewed since 2012 is 21%. 
  • Obesity is a known risk factor for neonatal death. Around 1 in 5 pregnant women in Leeds are obese (21% with a BMI over 30). 21% of mothers whose babies died neonatally were obese. Moreover, the 2016-17 analysis of CDOP data in relation to ethnicity highlighted high maternal BMI as a more prominent risk factor among women of Asian (53%) and African and Caribbean (45%) backgrounds. This finding was fed into a health needs assessment of maternal nutrition undertaken by LCC Public Health and has informed a developing programme of work with maternity services and other partners to address maternal nutrition in these groups. 
  • 17% of all neonatal deaths since 2012 reviewed by the Panel were considered to have modifiable factors. For Category 8: ‘Perinatal/neonatal event’, 20% were considered to have modifiable factors.


2019-20, key findings in relation to deaths of older children included:

  • The predominant categories of deaths were: ‘Chromosomal, genetic and congenital anomalies’ (15%), ‘Sudden unexpected, unexplained death (12%), ‘Malignancy’ (9%) and ‘Trauma’ (6%).
  • Approximately 3% of deaths among older children were from inherited conditions linked to cousin marriage. None of these deaths would be amenable to prevention through genetic counselling and intervention in families where genetic disease was already known to be present in the family.
  • The largest number of deaths was in babies between 28-364 days old (24%), and in children aged 1-4 years (18%). Fewer deaths occurred in the older age groups.
  • 60% of all older cases were considered to be modifiable and 6 recommendations were made in relation to these cases (outlined at point 6 of this report). Since 2012 onwards:
  • Trauma was a prominent cause accounting for 54 deaths (13%) since 2012, of which 22 were related to road traffic injuries, around half being pedestrians and a quarter passengers. 65% of the road traffic deaths were considered to have modifiable factors.
  • Since 2012, 32 Leeds babies have died suddenly and unexpectedly in their sleep, without an established underlying medical cause. Actual numbers fluctuate between 3 and 9 each year. 16 of these babies had one or more modifiable risk factors present (50%). The most prominent risk factor was household smoking (56%), bottle feeding (69%) and co-sleeping (81%). Drug and alcohol intake by parents on the night of death was present in 69% of these cases. It is not possible to ascertain any trend in this type of death because the  numbers are small. 
  • Children from all non-white ethnic backgrounds, comprised just 16% of all older child deaths, although these groups comprise of 19% of the population. 
  • Of the 292 deaths of older children reviewed since 2012, 107 (37%) were considered to have modifiable factors. The national figure for modifiable factors is 27% which includes both neonates and older children. The corresponding figure for Leeds deaths (neonates and older children) since 2012 is 29%, suggesting that classification by the Leeds CDOP aligns closely with national classification. The greatest potential for prevention among Leeds deaths, as described above, lies with sudden unexpected deaths of babies and road traffic injuries.

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