Agenda item

The Board considered a report of the Chair of the Child Death Overview Panel (CDOP)  County Durham and Darlington, with an analysis of emerging themes identified by the CDOP following a review of all child deaths in County Durham and Darlington where there were modifiable factors that could have contributed to the child’s death (for copy see file of Minutes).

The Chair of CDOP explained that the panel review all deaths of children who reside in County Durham and Darlington and look for any modifiable factors which are then reported to the Local Safeguarding Children Board.  He advised that two thematic reviews had been carried out and there were two recurrent themes found; Cardiotocography (CTG) interpretation and the escalation policy.

The Chairman welcomed the findings of the report and asked what could be done differently.  The Chair of CDOP said that STPs would need to pick this issue up and respond to the findings.  He had met with the Chair of the LSCB and the Chair of the Clinical Network to discuss the progress of maternity services, and had also written to NHS England to ensure this issue was raised regionally and nationally.  He had also met with the Coroner to make him aware of the issues. He advised the Board that Gill Findley, Director of Nursing and Vice Chair of the LSCB is actively involved in the development of the STP plans and is aware of the outcomes of the CDOP thematic review.

Councillor Gunn suggested that the Healthy Child Programme Board should also consider the report and its findings.

The Chief Executive of North Tees and Hartlepool NHS Foundation Trust found the report and its findings very timely and said it would be considered by the appropriate STP workstream.  He said that increasing maternity cover to 24 hours was a key priority but this would mean thinking about putting services on fewer sites to help this issue. He asked if any cultural issues had been uncovered during the review, between midwives and consultants working together.

The Chair of CDOP explained that they relied on documents provided from the Trusts and external notes of existing reviews.  This picked up some cultural and leadership issues including miscommunications between midwives and junior doctors.  

In response to a question from the Head of Children’s Public Health Nursing, Harrogate & District NHS Foundation Trust the CDOP Chair explained that there had been assurance that the action plan had addressed training and the buddy system.  

The Chief Clinical Officer, DDES CCG said that it was a helpful report and put into perspective the case for change in terms of hospital reconfiguration.  It was acknowledged that residents are passionate about their local services and were reluctant to see change however as the report shows doing nothing could affect lives.

Referring to change, the Director of Corporate Affairs/Trust Secretary, City Hospitals Sunderland NHS Foundation Trust said that during a recent consultation about maternity proposals for hospital reconfiguration in Sunderland and South Tyneside, residents were very passionate about keeping the services they currently have, although this CDOP review supported the view that there should be a reconfiguration to provide safe and effective services to mothers and babies.  The Board acknowledged that messages to the public should be clear that this is about saving lives.

The Head of Planning and Service Strategy said that there was strong support from the Board for the report and suggested that a letter be written to STP leads in relation to support for the paper.

The Chairman thanked the Chair of CDOP for sharing his report and findings.

Resolved:

(i)            That the findings of the CDOP Thematic Review be noted.

(ii)          That the learning points identified by the thematic reviews when considering plans for maternity and paediatric services be taken into account.