641 ‘Audit on CDOP (Child death overview panel) covering East Berkshire’

Abstract

<h3>Background</h3> Child Death Overview Panel (CDOP): All Local Safeguarding Children Boards(SCBC) are required to have a CDOP in order to improve the health, safety and wellbeing of other children. CDOP data is now electronically collected via eCDOP since 2018. <b>The key functions of CDOP:</b> Review all child deaths, excluding stillborn and planned terminations of pregnancy carried out within the law. Determine whether the death was preventable. To identify preventable and modifiable factors and improve practice Decide what, if any, actions could be taken to prevent such deaths happening in the future. To disseminate learning to appropriate professionals. Refer cases to the SCBC where there is suspicion of neglect or abuse. To investigate all the unexpected deaths. Usual procedure after a child dies: Joint agency response (JAR) meeting is done within 48hrs-5 days of an unexpected death. Morbidity &amp; Mortality meetings or Child death review meeting(CDRM) is done NEXT usually at the hospital where the patient has died (aimed to be done in 3months). CDOP Panel meeting (aimed to be done in 3–6 months) is done at the end when all (especially legal) work is completed and the case is usually then closed. <h3>Objectives</h3> To collect data from eCDOP to measure compliance in line with new guidance published in 2018 and implemented in September 2019. <h3>Methods</h3> <h3>Sample size</h3> 32 Sample was identified by using eCDOP online data base. <h3>Study Period</h3> Retrospective study covering a period since 01–09-2019 to 30–11-2020. It included all children who died in East Berkshire. <h3>Results</h3> 1. Total number of deaths- 32. <h3>Child deaths</h3> 25/32. Neonatal deaths: 7/32. 2. Expected Deaths: 23 Unexpected deaths: 9 3. Deaths in Local area: 20 Deaths whilst outside the area: 12 4. How many of unexpected deaths had a JAR meeting: 9 5. JAR held by: Local hospital: 6 Tertiary hospital: 3 6. How many Death notification forms had mentioned clearly discussion with the hospital medical Examiner: Mentioned =21 (Needed 8, Not needed 13) Not mentioned =11 7. Did JAR identify a Key Worker? In 9/9 unexpected cases. There was no documentation on eCDOP in expected cases. 8. Did the CDRM (Child death review meeting) or M&amp;M meetings took place? 31/32àyes CDRM has been done. Only 1/32 cases is very recent and awaiting CDRM. 9. Duration between death à CDRM à CDOP panel: Death à CDRM/M&amp;M: 0–100 daysà27 101–200 daysà3 200–300 daysà2 301–365 daysà0 Death à CDOP Panel: 0–100 daysà2 101–200 daysà3. 200–300 daysà5 301–365 daysà1 10. How many have been discussed at CDOP panel à 11 <h3>Conclusions</h3> The guidelines are being followed à Most of the JAR meetings, CDRM/M&amp;M are being conducted in time. CDOP meetings are getting delayed due to delays in legal process and getting the Post-mortems done. Some areas on eCDOP data base lack good documentation which needs improvement. During this process, many areas of good practice (clinical &amp; non clinical) and for improvement are identified. This helps in improving the system. Shared learning of innovative and excellence of practice leads to improved quality of care provided to all children across the country.