Executive summary
The death of any child is a tragedy. The role of the Child Death Overview Panel (CDOP) is to identify learning from the death of any child in Leeds. The annual report of the CDOP provides a summary of learning from reviewing these deaths and recommendations for partners who can implement lessons the panel has learned from this process to prevent similar events occurring in the future.
This year, 73 deaths were reviewed by the Child Death Overview Panel and Neonatal Death Overview Panel. Up to March 2025 there were 114 cases waiting review.
Of the deaths reviewed, contributory modifiable factors were identified in 36 cases (49%). In these instances, the factors were often overlapping and multiple. Some factors were directly related to death, others linked to circumstances in pregnancy that affected birth outcomes for the baby. These included:
- Maternal smoking, often in pregnancy, ten mothers
- Paternal smoking, seven fathers
- Factors in relation to access or provision of health service, six deaths
- Domestic abuse, four deaths
- Lack of supervision / neglect / abuse, four deaths
- Alcohol, four deaths
- Unmet emotional needs, three deaths
- Mould in the home, two deaths
- Drowning in rivers, two deaths
- High maternal body mass index (BMI), two deaths
- Co-sleeping, three deaths
- Substance use, two deaths
- Room too hot, one death
- Road traffic collision, one death
- Consanguinity, one death
- Murder, one death
- Home safety, one death
Recommendations
- The Director of Public Health to ensure that women and families have good access to pre-conception health advice and maintain good work on smoking, healthy maternal weight, genetic awareness, mental health, drug and alcohol use, vaccination uptake, accident prevention and safe sleeping.
- The Leeds Safeguarding Executive to run the Play Safe social media campaign, incorporating water safety, annually during summer; and the road safety team in Leeds City Council to continue to coordinate road safety and training by LCC and partners.
- Children’s social care, 0-19 PHINS and Children Centres to support parents to meet their children’s needs and improve coordination of and increased access to a range of support services and resources to help meet the needs of families affected by alcohol, smoking and substance use. Sharing responsibility to provide integrated accessible and evidence-based support through Best Start Hubs, Family Hubs, Early Start and Family Help approaches to ensure more families and children receive appropriate care and support.
- To work with housing colleagues to continue to raise awareness of the risks of and action to reduce the incidence of homes with mould and to ensure home safety messages are understood.
- The Leeds CDOP and NDOP to continue to work closely with health partners governance and safety processes to ensure lessons learned from child deaths are embedded in learning and practice.