Learning from children’s deaths: Systems approaches to analysis Following an introduction/welcome (15 minutes) This could include some sort of brief ice-breaker activity or a presentation by a local bereaved parent; along with introductions and housekeeping. This session (45 minutes) will provide an overview of the rapid response with a presentation and time for questions. It will link in with the later sessions on information gathering and case discussions, and the group activities. This should ensure that all participants are familiar with the overall process and different professional’s roles. Ideally this session should be presented by a local practitioner (health or police) who already has experience in the process of rapid response. If no such practitioner is available locally, an outside facilitator may be engaged; or a less formal approach to the presentation can be taken, using this overview to prompt discussion of what could be achieved locally.

What’s it all about? The process of systematically reviewing all children’s deaths is grounded in respect for the rights of children and their families, and geared towards preventing future child deaths.

How can we make child death review more effective? Data collection and collation Gathering and using relevant data Analysing the data Systems approaches Identifying effective preventive actions Disseminating lessons Implementing and monitoring recommendations Building and maintaining effective structures

Child death review process Ensure you have the right information in a useable format Evaluate the information using an appropriate framework Ask relevant questions about the circumstances, causes and context Use your analysis to inform worthwhile learning and action This provides a framework for approaching child death review. You may need to go back to earlier stages, e.g. if you find you are missing relevant information. It is helpful to work through in this order, so you don’t jump to inappropriate conclusions or action

Analysis Cause of death and case summary Four domains, factors graded 0 - III The child Family and environment Parenting capacity Service provision Categorisation of death; specific contributors Preventability Issues; learning; recommendations; action Form C provides a framework for evaluating the deaths. This should lead to a categorisation, and a decision about preventability. Consideration should be given in each case to whether there are lessons to be learnt, issues to address, or action to be taken. But keep recommendations to a minimum, specific and achievable. Need to emphasize that often Form C completed at local case review meeting DCSF will be collecting information on preventability.

Key questions What is the nature of the condition? Incidence and prevalence Aetiology Contributory factors Mortality Management and outcomes Is this death the tip of an iceberg? Is there any effective intervention?

Key questions What factors have we identified in any of the domains? To what extent are these isolated factors or indicative of wider systemic issues? What factors have we identified that may be amenable to intervention?

Systems methodology Recognises complexity Seeks to understand the underlying reasons that led individuals to act as they did Seeks to avoid hindsight bias Considers the viewpoint of the individuals at the time Transparent, structured approach to collecting and analysing data Uses research and case evidence to inform the findings Recap from introductory day Working Together (2013) states: LSCBs may use any learning model which is consistent with the principles in this guidance, including the systems methodology recommended by Professor Munro

A systems approach to analysis Adverse Outcome Systems methodology recognises that active failures may lead to an incident, which may in turn lead to an adverse outcome. Those active failures occur in a specific context which arises out of latent failures. There is the potential for barriers and defences at different stages. If we can address the latent failures, or improve the barriers and defences, we have a greater opportunity for avoiding such incidents.

A systems approach Barriers Defences Corporate Culture Adverse Outcome Child dies or is harmed Practitioner Task Errors or violations Local Environment Error-producing conditions Corporate Culture Management decisions and organisational structures OrganisationPrecursors Defences Individual Precursors Barriers This places the systems approach in the context of practitioner working

Factors that influence practice (based on Vincent et al, 1998) Corporate Culture Institutional context Economic and regulatory context Organisational and management factors Financial resources and constraints Organisational structure Safety culture Local environment Work environment Staffing levels and workload Equipment Team factors Communication Supervision and support Team structures Task factors Clarity of task Availability and use of protocols

Factors that influence practice (based on Vincent et al, 1998) Individual (staff) factors Knowledge and skills Motivation Physical and mental health Patient/client characteristics Complexity and seriousness of condition Language and communication Personality and social factors

A worked example 17 year old boy with cerebral palsy Admitted to DGH for gastrostomy Discharged after 2 hours Developed vomiting and lethargy Reviewed by CCN Found dead after 24 hours Autopsy revealed perforation secondary to paralytic ileus What were the key incidents or active failures that may have contributed to his death?

A worked example Patient/parent factors Individual staff factors Surgeon CCN Paediatrician GP Task factors Team factors Work environment Organisational and management factors Institutional context

Child death review process Ensure you have the right information in a useable format Evaluate the information using an appropriate framework Ask relevant questions about the circumstances, causes and context Use your analysis to inform worthwhile learning and action This provides a framework for approaching child death review. You may need to go back to earlier stages, e.g. if you find you are missing relevant information. It is helpful to work through in this order, so you don’t jump to inappropriate conclusions or action

Taking action to prevent child deaths Education: Strengthening Individual Knowledge and Skills (Practitioners) Empowerment: Informing the public (community education) Mobilizing communities Enforcement: Influencing policy and legislation Advocacy and health promotion Engineering: Modifying the physical environment Changing organisational structures and practice

Developing recommendations and action plans Is this strategy relevant and likely to make a difference? Is there any published evidence of its effectiveness? Could it cause any harm? Is it likely to be achievable in our local context? Develop an appropriate action plan, implement, and review

Achieving effective outcomes Disseminating Learning Learning Lessons Understanding Motivation Information (Data) Stories Developing appropriate recommendations and action plans talk through how we use information, stories and skills to achieve effective action Data are important for our understanding – both individual case data, but also wider information to understand the context and relevant evidence to understand the case Narrative data (stories) are also important, as they provide the motivation for change, set the information in a real context Recommendations and action plans will be covered later Implementation

Summary Child death review stems from respect for the child and family Many child deaths are potentially avoidable Joint agency working is essential Child death review should lead to positive action to safeguard and promote the welfare of children This requires effective and appropriate information gathering and analysis; formulation, implementation and monitoring of relevant (evidence-informed) actions; dissemination of learning appropriate structures This is to summarise; the remainder of the course will build on all aspects with more detail. I suggest moving straight on rather than taking questions at this stage.