How the deaths of 84 children in Norfolk were caught in a review delays

More than 80 deaths of children were caught in backlog. Dominic Lipinski/PA Wire

More than 80 deaths of children were caught in backlog. Dominic Lipinski/PA Wire - Credit: PA

Problems with a panel which looks into the deaths of children in Norfolk meant more than 80 cases where youngsters had died had not been reviewed.

Ofsted inspectors picked up on the issue around the Norfolk Local Safeguarding Children Board's (NSCB) Child Death Overview Panel during their 2015 inspection.

The panel is meant to review information on all child deaths, looking for possible patterns and potential improvements in services, with the aim of preventing future deaths.

But when inspectors visited in 2015 they found there were 84 cases where children who had died had not been reviewed.

The report said the work of the panel was 'underdeveloped', with the panel's 2013-14 annual report not completed and a third of its meetings having been cancelled because of 'inconsistent attendance' by clinicians.


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Subsequently, David Ashcroft, who has worked as a director in children's services departments for the past 25 years, has become the head of the safeguarding board.

All the cases which had not been reviewed have now been dealt with and actions taken to improve systems and processes.

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Dealing with the 80 plus cases which were not reviewed meant the board reviewed 106 child deaths in 2015/16. Just under a quarter of cases were assessed as having modifiable factors - those are factors which 'by means of nationally or locally achievable interventions, could be modified to reduce the risk of future child deaths'.

The majority of the deaths (79) were due to medical reasons, of which 10pc were assessed as having modifiable factors.

But there were three child deaths due to deliberately inflicted injury, abuse or neglect and two due to suicide or deliberate self-inflicted harm. The assessment of the panel was that all of those had modifiable factors.

We asked the county council whether, in those five cases the children and families were known to children's services and if any had been subject to a published or commissioned serious case review.

The council's reply was: 'The names of the children and details that could identify them are not published and the board cannot comment on individual cases.

The Child Death Overview Panel is also the responsibility of the board and is chaired by the director of public health.

'Its remit is to examine all child deaths in Norfolk, to see if there are any consistent patterns with implications for health and care services in the county.'

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