1. Child Death Review Pilot
6 October 2010
Child Death Review Pilot
Child Death Review Pilot
Presenter: Beverley Heatman

2. Background
An analysis of child deaths is at the heart of any study of child health
Interesting as national mortality figures are, they do not give enough detail to focus on prevention both at a local and national level
There is a need to investigate deaths in more detail, focussing on prevention, hence Child Death Reviews (CDRs).
Child Death Review Pilot

3. Child Death Reviews
Were first established in California in 1978 as a result of concern on the part of parents and professionals over the increasing number of preventable deaths
Now all States in the USA apart from Idaho have a CDR process in place
Also in Australia, New Zealand and Canada and more recently in England
So lets look at what has happened elsewhere. Our colleagues in the States started the ball rolling and established a child death review process in This came about as a result of concerns expressed by parents and professionals about the number of “preventable deaths” that were being experienced.
Now every state in the USA has a child death review process, though the state of Idaho are working to recommence their death review team as soon as funding become available (sounds familiar!)
Similarly there are established processes in Australia, New Zealand and Canada ……………. Even just across the border in England there is an established child death review process.
Child Death Review Pilot

4. Serious Case Reviews Child Death Review Pilot
All parts of the UK have similar processes for reviewing deaths from child abuse and neglect
Statutory obligation of LSCBs to undertake a serious case review
However this is limited by criteria, i.e. abuse or neglect must be known to be a factor or suspected; or a child must have committed suicide; or has been killed by a parent with a mental illness
Identifies lessons to be learned from inter-agency working
Child Death Review Pilot

5. Child Death Review Key Purpose
To conduct a comprehensive review of child deaths, to better understand how and why children die, and use the findings to take action that can prevent other deaths and improve the health and safety of children.
Child Death Review Pilot

6. England
In England Child Death Reviews were introduced as a Statutory requirement under the Children Act 2004; started about three years ago.
Local Safeguarding Children Boards took the lead in this multi-disciplinary process.
Funded for a period of 3 years (up to March 2011)
Child Death Review Pilot

7. England – Pros/Cons
Legislative obligation for LSCBs to review all child deaths 0-18 years
Development of Rapid Response Team to all unexpected child deaths
Health driven
Local reviews undertaken
Area specific - No national review
Impedes information sharing on a National basis
Individual reviews rather than thematic reviews are undertaken
Limits the ability to identify trends or themes
Child Death Review Pilot

8. What’s happening in Wales?
In 2008, the Welsh Assembly Government agreed to
support a Child Death Review Pilot in Wales
Population base of LSCBs is significantly less than the recommended 500,000 for child death review
Not a legislative process for LSCBs to review all child deaths
Child Death Review Pilot

9. All Wales Child Death Review Pilot
Pilot study from July 2009 to extended to March 2011
Establishment of National Child Death Review Team
Team Members
Clinical Lead (Prof J Sibert)
Manager (Beverley Heatman) (previously Caroline Busby until March 2010)
Support Officer (Lucy Wood)
Designated Doctor - Child Protection & Safeguarding Children (Dr A Naughton)
Team hosted by Public Health Wales
Review all child deaths 0-18 years
Pilot documentation
Data collection commenced October 2009
All Wales database development
Child Death Review Pilot

10. Objectives Ascertaining all child deaths (0 to <18 years)
Establishing national reviews of deaths
Testing the feasibility of establishing local case discussions and reviews
Child Death Review Pilot

11. Ascertainment
Data is currently being collected using standard form [Form A] (based on the Form in England, though these forms are being revised in line with the information was are identifying as required)
Information relating solely to deceased
Not subject to Data Protection Act, but duty of confidentiality remains
Started in full October 1st 2009
So far we have had identified 193 child deaths through various sources since commencement of the data collection.
Child Death Review Pilot

12. Key Sources Child Death Review Pilot
LSCBs (received mainly from Registrars) -variable response
Office of National Statistics (ONS)
Clinicians including Welsh Paediatric Surveillance Unit
SUDI meetings
Coroners Rule 57a issued in Wales with effect of 1 April 2010
More recently, information is being cross matched with Patient Episode Database Wales (PEDW) and Welsh Demographics Service (WDS)
Child Death Review Pilot

13. Issues encountered Data Protection/Confidentiality
Information related to the deceased and therefore not subject to Data Protection Act, however, duty of confidentiality remains
No dedicated resource for process within organisations
Informing Families
Telling families that limited information about their child’s death will be collected
Child Death Review Pilot

14. Informing Families Expected Unexpected Child Death Review Pilot
Basic information provided through hospital bereavement processes
Routine information collected, leaflet provided
Duty Consultant Paediatrician
Unexpected
More detailed information provided at start of SUDI process by professional identified at initial meeting
Likely to be subject to review
Child Death Review Pilot

15. “Procedural Response to Unexpected Death in Children”
PRUDiC
A document detailing the
“Procedural Response to Unexpected Death in Children”
is under development and is expected to
supersede the current “SUDI protocol”
Child Death Review Pilot

16. National Reviews Panel Purpose Outcome Child Death Review Pilot
Fixed core membership including representatives from health, social care, police
Option to co-opt other professionals/individuals who can make a contribution
Purpose
Identify patterns or trends emerging locally or nationally
Focus on findings of reviews and preventative factors
Outcome
Variable dependant on the theme being reviewed and the engagement required
Multi-sectorial workshops to produce action plans for dissemination and implementation
Child Death Review Pilot

17. National Reviews Current Reviews: Future reviews planned
Suicides or apparent suicides (report pending)
SUDIs and Overlaying (report pending)
Quad Bikes & Mini-motos (report pending)
Future reviews planned
Medical deaths where there are lessons for all of Wales
Asthma
Intestinal failure
We differ in our approach from England as we want to consider deaths from similar causes.
Child Death Review Pilot

18. Suicides 2006-2009 Child Death Review Pilot
21 Cases were reviewed in total
Consent was obtained to review only a minority of these, however some very important illustrative points were identified.
First panel meeting held in March 2010; with a further panel meeting held in June 2010
Agreed to use publicly available information relating to other cases
Multi-sectorial workshop is being arranged to share the conclusions of the National panel and to develop recommendations and an action plan.
Child Death Review Pilot

19. SUDIs and Overlaying
We used information available through transcripts of the Inquests from Cardiff & the Vale areas for 2009.
We obtained permission of the Coroner Ms Hassell
Two panel meetings have been held; one in June 2010 and another in September 2010.
Child Death Review Pilot

20. Quad Bikes & Mini Motos Publicly available information was used
Eighteen deaths were identified across the UK (three of whom were <4 years)
Five females
Thirteen males
Eight deaths involving quad bikes
Ten deaths involving mini-motos
Higher incidence in Northern Ireland
Child Death Review Pilot

21. Wales Pros/Cons All Wales approach
Looks at the circumstances surrounding the death
Identifies preventable factors
Looks at all child deaths and aggregates the information
Produces recommendations for prevention of future deaths
Child Death Review Pilot

22. Wales – Pros/Cons Consent has to be obtained for 3rd party information
Local Safeguarding Boards are not obliged to assist in the process
Child Death Review Pilot

23. Next Steps
Report is being submitted to the Welsh Assembly Government for an all Wales National Child Death Review programme to continue following completion of the pilot
Our primary and key recommendation will be that the Welsh Assembly Government must facilitate making this a statutory obligation
Child Death Review Pilot

24. Future for the pilot Wider stakeholder engagement
Integration of PRUDiC with Child Death Review Process
Document development
Database development
Suicides Multi-sectorial workshop to develop recommendations and action plan
Await outcome from WAG
Child Death Review Pilot

25. Thank you
Any questions?
Child Death Review Pilot