Publication - Report

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

Published: 8 May 2014
Part of:
Health and social care
ISBN:
9781784124489

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.

56 page PDF

926.7 kB

56 page PDF

926.7 kB

Contents
Child Death Review Report : Scottish Government Child Death Review Working Group
Options to consider for Scotland

56 page PDF

926.7 kB

Options to consider for Scotland

1. Maintain the Status Quo: no changes to present systems and process

2. Adapt existing models of review for child deaths

3. Develop a national model for reviewing Child Deaths in Scotland

1. Maintain the Status Quo : no changes to present systems and process

Advantages

Disadvantages

There are a number of review processes of varying number and quality across Scotland that may be able to be adapted into a national system.

Continue to utilise 'high level' mortality data provided into UK-wide systems e.g. MBRRACE.

There is no standardised process to learn lessons from childhood deaths or to gather detailed data on the causes and circumstances of the death.

Families of children who have died may find the status quo unacceptable.

There is now data indicating variation in mortality rates in the 4 countries of the UK. Without appropriately detailed Scottish mortality data little can be done to identify causes and patterns of mortality and allow opportunity to reduce mortality rates.

2. Adapt existing models of review for child deaths

A. The Significant Case Review system used by local Child Protection Committees.

B. SUDI Toolkit process used for cot deaths.

C. New process for Adverse Incident Reporting systems by HIS.

D. Use existing models of data collection to identify patterns of death in under 18s.

A. The Significant Case Review (SCR) system used by local Child Protection Committees

Advantages

Disadvantages

This is an established multi-agency process that examines some, though not all, child protection deaths in considerable detail.

New guidance will ensure that the Care Inspectorate will become the repository for SCR reports in Scotland and be responsible for dissemination from the reports.

The SCR process is prolonged and complex.

The process is currently being reviewed in Scotland. Revised guidance is scheduled to be published in late Spring 2014.

Only a small minority of deaths in childhood are related to child protection issues and so this process would not capture the majority of child deaths.

There is limited involvement of families, although recent research in England, in relation to family involvement in maltreatment case reviews, found that contrary to professionals' views, families were keen to participate in reviews, their desire for something to be redeemed from the tragedy over-riding their concern of further distress.(Morris et al., 2013)23

B. HIS process used for reviewing sudden unexpected deaths in infancy (SUDI process)

Advantages

Disadvantages

This is an established multi-agency process with defined roles and responsibilities for all involved and appears to be like a confidential enquiry.

Detailed and time-consuming data collection form, with qualitative and quantitative items, is not user-friendly.

The SUDI process is designed for a specific category of infant deaths and would be unlikely to be appropriate for the significant heterogeneity of children and young person's deaths across a wide age range. While there is a data collection process, there has been no formal analysis and national report.

The significant heterogeneity of childhood and young persons' deaths outside infancy, can complicate data requirements. While there is a data collection process, there has been no formal analysis and national report.

C. HIS Adverse Incident Reporting systems24

Advantages

Disadvantages

This is a national system that applies consistent definitions and a standardised approach to adverse event management across NHS Scotland. It aims to learn from adverse events and promote patient safety.

It is designed to capture health-related adverse incidents only. There is limited multi-agency involvement and it cannot take account of the significant number of child deaths that occur outside healthcare settings, e.g. as a result of road traffic accidents (RTA).

Many childhood deaths will not be applicable for an adverse incident framework.

D. Use existing models of data collection to identify patterns of death in under 18s, in collaboration with HQIP NHS England. Data sources include:

  • death certification data from NRS and ISD data
  • National perinatal data collection linking into MBRRACE-UK
  • SUDI data collection - HIS.

Advantages

Disadvantages

Utilisation of existing data collection systems will improve accuracy of data capture and decrease overlap with any new data collection systems.

Systems have varying levels of development and maturity.

These systems are generally designed to capture, for surveillance purposes, 'high-level' health service related data. As such, they cannot provide the level of detail needed to adequately review a child's death (like a confidential enquiry).

Most cannot capture data outside health although data linkage with education and social care systems are developing in one Health Board area.

3. Develop a national model for Scotland reviewing Child Deaths in Scotland

Set up a steering group to develop a national child death review process in Scotland and to identify costs and funding which will be informed by pilot work currently being undertaken (Appendix 8, Tayside pilot). The model includes:

  • A multi-agency care pathway and set of standards for use in the event of childhood deaths in Scotland.
  • A multi-agency CDR panel to meet to review and collate appropriate data relevant to the death of a child or young person. This is being piloted at Health Board level but without prejudice to other geographical or organisation groupings.
  • A pilot of a working dataset allowing:
    a. appropriate gathering of data
    b. integration with other existing datasets and
    c. the ability to feed into national and international data collection.
  • A framework of agreed standards for communication with families about the process and outcomes. This would include how, when, and who.

Advantages

Disadvantages

A consistent system across Scotland which enables data collection and analysis, dissemination of themes and informing policy with the potential to reduce child and young people mortality.

Informed and sensitive communication with bereaved parents.

Putting into practice lessons learned from the pilot of the CDR process.

Time taken to set up a national process.


Contact

Email: Mary Sloan