1. Child Death Review Process
By Paul Wright
Designated Doctor for Child Deaths in Surrey
Child Death Review Process

2. Introduction
Why Jason Died
Child Death Review Process

3. Introduction Introduced in Working Together 2006
Statutory since 1st April 2008
Consists of two interrelated processes for reviewing Child Deaths

4. Introduction Introduced in Working Together 2006
Statutory since 1st April 2008
Consists of two interrelated processes for reviewing Child Deaths

5. Introduction 2
1. Rapid response by a group of key professionals who come together for the purpose of enquiring into and evaluating each unexpected death of a child
2. An overview of all child deaths up to the age of 18 years (excluding both those babies that are stillborn and planned terminations of pregnancy carried out within the law) in the LSCB area, undertaken by a panel
Child Death Review Process

6. What is an unexpected death? Child Death Review Process
In this guidance an unexpected death is defined as the death of an infant or child (less than 18 years old) which:
Was not anticipated as a significant possibility for example, 24 hours before the death; or
Where there was a similarly unexpected collapse or incident leading to or precipitating the events which led to the death
Child Death Review Process

7. Processes for Unexpected Deaths Child Death Review Process
There are two separate processes followed unexpected deaths:
1. Neonates on Neonatal Unit
2. All other Children
Child Death Review Process

8. Neonatal Deaths Child Death Review Process
We consider Neonatal deaths to include all Children born prematurely
All Children born at term, or near term will follow the normal Child Death Processes
These Deaths do not initiate a Rapid Response
Information is collated and reviewed by a co-opted Consultant Neonatologist
Child Death Review Process

9. Unexpected Deaths in Hospital Child Death Review Process
Normal Hospital procedures should take place
Families should be allocated a member of Hospital Staff to remain with and support them
Hospital Staff should contact the Coroner
Hospital Staff should contact the Child Death Review Coordinator to inform them of the Child Death
Child Death Review Process

10. Unexpected Deaths in the Community Child Death Review Process
These Children should normally be taken to an A&E department rather than the mortuary
There are times when it is clearly inappropriate to take a Child to A&E
Resuscitation should always be initiated unless clearly inappropriate
The Child should be examined by a Consultant Paediatrician and a detailed and careful history of the events taken
Child Death Review Process

11. Unexpected Deaths in the Community 2 Child Death Review Process
Hospital Staff should contact the Coroner
A&E should then contact the Child Death Review Coordinator to inform them of the Child Death
Appropriate support should be offered to the family including where available:
Bereavement Counsellor
Hospital Chaplin
Faith Leader
Child Death Review Process

12. Rapid Response Child Death Review Process
Each LSCB has set up its own procedures for providing rapid response
Some LSCBs have pooled resources so that rapid response is carried out across a number of LSCBs
Child Death Review Process

13. Rapid Response in Surrey Child Death Review Process
Led by Rapid Response Nurse – Liz Seymour
She will:
Make contact with the family
Explain to them the Child Death Process
Take the History of events leading to the Death
Present any questions or concerns that they may have
Will advise the family of where to access support
Feedback to the family any results of the investigation
Child Death Review Process

14. Rapid Response in Surrey 2 Child Death Review Process
Rapid Response should take place within a week of the death
However this can be delayed if the family wish it to be
There are occasions when Rapid Response is inappropriate
Child Death Review Process

15. Child Death Review Child Death Review Process
This is a set review to bring together information about the events leading up to a Child’s death
It is a multi-professional meeting. Those who are generally invited include:
Named Nurse
General Practitioner
School Nurse/ Health Visitor
Hospital Paediatricians
Child Death Review Process

16. Child Death Review 2 Child Death Review Process
Other Professionals invited:
Hospital Nursing Staff
Tertiary Consultants
Social Care
Police
School
Educational Psychologist
Ambulance Staff
Coroner’s Officer
Other Professionals may be invited dependant on review
Child Death Review Process

17. Child Death Review 3 Child Death Review Process Aims of the Review:
To look at the events leading to the Child’s death
To look and see if any changes in management may have prevented the death
To get a holistic picture of the Child
To look at the support the family are receiving
To look at the preventability of the death
To categorize the death
To consider referral for an SCR
Child Death Review Process

18. Preventability Child Death Review Process
Government Statistics consider 3 categories which are reported on at the end of the year:
Unpreventable
Partially Preventable
Preventable
Child Death Review Process

19. Categories of Deaths Child Death Review Process
This Classification is hierarchical: where more than category could reasonably be applied, the highest up the list should be marked
1. Deliberately inflicted injury, abuse or neglect
2. Suicide or deliberate self-inflicted harm
3. Trauma and other external factors
4. Malignancy
5. Acute Medical or Surgical Condition
6. Chronic Medical Condition
Child Death Review Process

20. Categories of Deaths 2 Child Death Review Process
7. Chromosomal, Genetic and Congenital anomalies
8. Perinatal/ neonatal event
9. Infection
10. Sudden Unexpected, Unexplained death
Often categorization of the death has to wait until the inquest has taken place
Child Death Review Process

21. Child Death Overview Panel Child Death Review Process
This is a Statutory Panel which meets every 2 months in Surrey
It is chaired by an Independent Chair
It is a multi-professional panel
Child Death Review Process

22. Child Death Overview Panel 2 Child Death Review Process
Representatives include:
Health
Social Care
Police
Ambulance
Coroner’s Office
Voluntary Sector (CHASE Hospice)
Public Health
Risk Manager, NHS Surrey
Child Death Review Process

23. CDOP Functions Child Death Review Process
CDOP has many functions which are defined in Working Together 2010
These include:
Determining Preventability on all deaths
Collecting and collating the minimum data set on each child
Evaluating the data set and identifying lessons to be learnt or issues of concern
Child Death Review Process

24. CDOP Functions 2 Child Death Review Process
Reviewing specific cases in detail
Referring to the Chair of LSCB if there are grounds to undertake further enquiries e.g. SCR
Monitoring support and assessment services to the families of children who have died
Identifying any Public Health issues
Co-operating with regional or national initiatives
Child Death Review Process

25. Surrey Child Deaths 2011 - 2012 Child Death Review Process
Surrey Children
Non-Surrey Children
Total Child Deaths
<1 month 31 18 49
1 month to 1 year 11 4 15
1 year to 4 years 3 7
5 years to 9 years 1
10 years to 14 years
15 years to 17 years 5
Total 56 27 83
Child Death Review Process

26. Resident Surrey Child Deaths 2011 - 2012 Child Death Review Process
Male
Female
<1 month 17 14
1 month to 1 year 5 6
1 year to 4 years 2
5 years to 9 years 1
10 years to 14 years
15 years to 17 years
Total 30 26
Child Death Review Process

27. Unexpected Surrey Child Deaths 2011 - 2012
Male
Female
Total
<1 month 1 2
1 month to 1 year 3 4 7
1 year to 4 years
5 years to 9 years
10 years to 14 years
15 years to 17 years 8 9 17
Child Death Review Process

28. Child Death Reviews 2011 -2012 Child Death Review Process
17 Cases reviewed between April 2011 and March 2012
Of these:
4 Sudden Unexpected Death in Infancy
4 acute medical or surgical conditions including 2 SUDEPs
3 infections
1 drowning
1 equipment failure
4 awaiting categories
Child Death Review Process

29. Child Death Reviews 2011 -2012 Child Death Review Process
3 Deaths were referred to the Serious Case Review Group
Of these:
One went to Serious Case Review
One to Case Review
One did not proceed
Child Death Review Process

30. Child deaths 2011-2012 by category and sex
Category of death
Male
Female
Deliberately Inflicted injury, abuse or neglect
Suicide or deliberate self inflicted harm
Trauma and other external factors 2
Malignancy
Acute medical or surgical condition 3
Chronic medical condition 1
Chromosomal, genetic and congenital abnormalities
Perinatal / Neonatal event 10 7
Infection
Sudden unexpected, unexplained death
Awaiting categorisation (9: Neonatal, 3: waiting for post mortem results) 6 8
Total 30 26
Child Death Review Process

31. Preventable Deaths Child Death Review Process
6 Preventable Deaths between April 2011 and March 2012
1 died overseas
2 died of SIDS although evidence of co-sleeping and drug/ alcohol use
1 drowning in the bath
1 due to overwhelming infection not recognized by medical professionals
1 due to equipment failure
Child Death Review Process

32. Learning Child Death Review Process Learning points to be considered:
There have been a number of deaths associated with co-sleeping, and with a history of alcohol and drug use. CDOP feels that a co-sleeping campaign is required
There are still issues about the notification of deaths in children who are not taken to A+E, i.e. the child is pronounced dead at the scene
Listening to the parents about feeding problems in newborns
Child Death Review Process
Child Death Review Process

33. Learning 2 Child Death Review Process Additional Learning Points:
A need to examine neonatal deaths in detail
Lack of minimum standards for laboratory investigations after child deaths in Surrey
Child Death Review Process

34. Thank you