1. 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.

2. 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.

3. 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

4. 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

5. 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.

6. 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?

7. 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?

8. 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

9. 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.

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

11. 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

12. 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

13. 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?

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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.