Child Death Review Report : Scottish Government Child Death Review Working Group

A report by a Scottish Government short-life working group which explored current practice in Scotland and considered whether Scotland should introduce a national collaborative multi-agency system for reviewing the circumstances surrounding the death of a child.

Key elements of a Child Death Review (CDR) system

34. The key elements of a CDR system are:

1. A local CDR process includes:

  • local notification of child deaths, collation of available information, identification of further data needed
  • convening a multi-agency CDR panel, with core and case-specific membership to share and collate information about the circumstances around an individual child's death, to create a narrative account of the circumstances
  • the completion of an agreed national standardised data-set for each child's death
  • timely and appropriate involvements of bereaved families
  • mechanism for local dissemination of learning

2. A national process includes:

  • learning lessons, developing good practice, disseminating information and implementing change across agencies
  • Collating and disseminating local and national data to identify common themes on avoidable deaths and
  • Establishing a strategic group which examines data trends and reviews recommendations to make appropriate recommendations to policy makers and public health.

35. Any implementation of a child death review system in Scotland should take account of other processes including: SCRs, SUDI reviews, neonatal or paediatric mortality review processes, patient safety programmes and may be further informed by the results of the death investigation carried out by the Procurator Fiscal.

36. The system should avoid duplication of existing data collection and use data linkage techniques to provide a comprehensive child death dataset for Scotland.

37. The system should maximise all opportunities to prevent child deaths.


Email: Mary Sloan

Back to top