Dozens of children have died in Brighton and Hove over the past few years and experts have been trying to learn and share any lessons that could save lives in the future.
More than 100 children have died in Brighton and Hove in the past six years. A little-known official body – the Child Death Overview Panel – reviews each death.
The panel must decide whether a serious case review is needed. It must also decide whether a child’s death raises matters of concern affecting the safety and welfare of children in the area. And whether there are any wider issues arising from an individual death or from a pattern of deaths.
The Child Death Overview Panel for Brighton and Hove has a wider East Sussex remit and reports to the Local Safeguarding Children Board for each area. In the past year it has made a number of recommendations to the Brighton and Hove Local Safeguarding Children Board. Some were specific to individual cases and had no wider relevance.
But the panel wants the clinicians who cared for a child who died to have better opportunities to discuss cases with pathologists and the coroner when post-mortem tests and inquests take place.
It also wants to explore how to raise the profile nationally of the benefits of breast milk banks. The aim is to reduce the risks of babies developing necrotising enterocolitis.
From April last year to March this year the panel was notified of 52 deaths of children. Of those, 16 were from Brighton and Hove. Most of the deaths involve new-born babies – those up to a month old – with babies under
a year old falling into the next highest age group. The stats dip until children reach their teens when the number of child deaths starts to rise again.
The panel reviewed 44 deaths during the year – 18 were children from Brighton and Hove. There is always a delay between a child’s death and the review taking place although staff sickness added to this over the past year.
The aim of a review is to determine whether a child’s death could have been prevented. If so, the panel has to decide what actions, if any, could reduce the risk of future deaths.
“Modifiable factors included inappropriate sleeping arrangements for babies and high-risk pregnancies where there were problems with the obstetric and midwifery care”
In Brighton and Hove the Local Safeguarding Children Board annual report, which was published last week, said: “Of the 11 reviews that were completed during the year that had modifiable factors nine related to babies.
“Modifiable factors included inappropriate sleeping arrangements for babies and high-risk pregnancies where there were problems with the obstetric and midwifery care.
“All of the cases reviewed were very different and there were no obvious patterns or trends that could be identified.”
Despite the pain of bereavement, parents have taken part in most of the reviews of child deaths beyond the neonatal period over the past year. Among other things, they provide feedback on the services that they and their children received.
The safeguarding annual report also covered wider child protection issues for the 50,000 under-18s living in Brighton and Hove. It covers the first full year since the former Brighton and Hove police chief Graham Bartlett became the independent chairman of the safeguarding children board.
The report said: “While it is not possible to know every child at risk in Brighton and Hove due to the often duplicitous and secretive nature of abuse and neglect, keeping children safe will always be our number one priority.”
The report said: “Many groups of children in Brighton and Hove are vulnerable.” It highlighted some groups that were particularly so. They included those subject to or at risk of child sexual exploitation, those missing from home, education or care, trafficked children and those who have been privately fostered.
Mr Bartlett’s report is as diplomatic as those of his predecessor, Alan Bedford, who came from an NHS and social work background. It recognises the way that Brighton and Hove City Council social workers are liaising more closely with Sussex Police and NHS clinicians.
But it flags up concerns too. Some related to information sharing and management oversight. Mr Bartlett has promised greater scrutiny in the current year as he strives to make sure our children – especially the most vulnerable – stay safe.