Child Death Overview Panel Annual Report

Executive Summary

The Leeds Child Death Overview Panel (CDOP) has been undertaking its role to review the death of every child aged under 18 who were 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.

National Findings from the review of child deaths

In 2021 the National Child Mortality Database published a report titled Child Mortality and Social Deprivation[1]. Commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England, this report includes analysis of 3,347 children who died in England between 1 April 2019 and 31 March 2020 and investigates the characteristics of their deaths to identify if socio-economic deprivation is associated with childhood mortality.

The report, which is based on data for children who died between April 2019 and March 2020 in England, finds a clear association between the risk of child death and the level of deprivation (for all categories of death except cancer).

In its findings, the most common age at death was less than 1 year (63%) and more boys than girls died (56.5% vs 43.5%), while the majority of children who died lived in urban areas (87.8%). By linking each child’s address to the UK government’s ten deciles of deprivation (calculated using seven indicators of income, employment, education, health, crime, access to housing and services, and living environment), it was determined that child mortality increased as deprivation increased. More specifically, on average, there was a 10% increase in the risk of death between each decile* of increasing deprivation.

For deaths that were reviewed by a Child Death Overview Panel (CDOP) as part of the national Child Death Review (CDR) process, the report was able to provide further insights. A total of 2,738 child deaths were reviewed in the period from 1 April 2019 to 31 March 2020 (though the year of death ranged from 2012 to 2020) and, of these, we were able to link 98% to deprivation deciles. Analysis of these more detailed data shows that the proportion of deaths with modifiable contributory factors increased with increasing deprivation (factors relating to the social environment were the most common). While, overall, at least 1 in 12 of all child deaths reviewed had one or more factors related to deprivation identified. In Leeds around a third of bookings are for women resident in deprived Leeds – for example in 2017 there were 9,867 bookings in Leeds, with 33% (3,284) of these mothers residing in the most deprived decile[2].  Some ethnic groups are almost entirely resident in deprived Leeds. This has reduced slightly over the years, but almost 80% of Bangladeshi babies and around 70% of African babies continue to be born in deprived Leeds. The CDOP will explore further the impact of social deprivation in Leeds and its links to child death through its recommendations.

In Leeds, our reviews identify two key areas where there may be modifiable factors that can support the reduction of child deaths.

Sudden Infant Death Syndrome (SIDS)

Tragically, some babies die suddenly and unexpectedly in their sleep and there is often no clear cause of death that can be given however, the CDOP has identified a number of factors in 11% of all neonatal and baby deaths that can increase the risk of death. Smoking, bottle feeding (breast feeding is a known protective factor) unsafe sleeping practices, and sometimes the use of alcohol or drugs that can impact on providing the safe care of babies. Domestic violence can also be a feature in these families as well as parents who have emotional or mental health issues. The CDOP is reassured that safety messages are given, sometimes on numerous occasions, to parent’s pre and post birth however these types of modifiable factors continue to be a feature in our annual reports.

Trauma in older young people

And secondly, deaths from traumatic causes, particularly road traffic deaths. Trauma and other external factors’, account for 53 (14%) deaths since 2008, of which 31 were road traffic injuries; 14 victims were pedestrians; 10 victims were passengers; 2 were drivers and 5 were on motorbikes. Of the road traffic injuries, 24 of 31 (77%) were considered to have modifiable factors. Stronger links are being made with road safety partnerships to consider how road safety messages are given to young people to try and reduce such deaths. Further to this, the LSCP have developed campaigns targeted at parents and carers to remind them of the importance of reflective equipment when out in the evening[3].

Overall Key findings in relation to neonatal deaths

  • 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 reviewed 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 the cohort of women experiencing neonatal deaths since 2012, 12% 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 deaths. The rate of maternal smoking identified in cases reviewed since 2008 is 20%.
  • Obesity is a known risk factor for neonatal death. Overall, around 1 in 5 pregnant women in Leeds are obese (21% with a BMI over 30 rising to 25% for those living in the most deprived areas[4]). 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.
  • 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.

In 2020-21, key findings in relation to deaths of older children included:

  • The predominant categories of deaths reviewed were: ‘Chromosomal, genetic and congenital anomalies’ (39%), and ‘Sudden unexpected, unexplained death (28%)
  • Approximately 8 (18%) of deaths reviewed among older children were from inherited conditions linked to cousin marriage. Two of these deaths could 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 (29%), and in children aged 5-9 years (21%). Fewer deaths occurred in the older age groups.
  • 38% of all older cases were considered to have modifiable factors.

Overall Key findings in relation to older children’s deaths

  • Trauma was a prominent cause accounting for 53 deaths (14%) since 2008, of which 31 were related to road traffic injuries, 14 being pedestrians and 10 passengers. 69% of trauma deaths were considered to have modifiable factors.
  • Since 2008, 65 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. 58 of these babies had one or more modifiable risk factors present. The most prominent risk factor was household smoking (83%), bottle feeding (52%) and co-sleeping (45%). Alcohol intake or drugs used by parents on the night of death was present in 33% of these deaths. 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 28% of all older child deaths, although these groups comprise of 19% of the population in Leeds[5].
  • Of the 381 deaths of older children reviewed since 2008, 146 (38%) were considered to have modifiable factors. The national figure for modifiable factors is 31%[6] which includes both neonates and older children. The corresponding figure for Leeds deaths (neonates and older children) since 2008 is 31%, suggesting that classification by the Leeds CDOP aligns 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.

[1] Leeds Observatory – Population

[2] Main-Text-FINAL-WEB.pdf (

[3] Leeds-Maternity-Health-Needs-Assessment-April-2020-FINAL.pdf

[4] LSCP - Parents Carers Family (

[5] Leeds-Maternity-Health-Needs-Assessment-April-2020-FINAL.pdf

[6] NCMD-Child-Mortality-and-Social-Deprivation-report_20210513.pdf

For a full copy of the CDOP Annual report please email the LSCP Business Unit with your request.

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