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.

Appendix 1: Child Death Review Group Membership

Dr Kate McKay (Chair) Senior Medical Officer, Scottish Government
Dr Rob Ainsworth Forensic Pathologist, NHS Lothian
Dr Vicky Alexander Consultant Paediatrician, NHS Tayside
Ms Denise Bruce Crown Office and Procurator Fiscal
Ms Claire Burnett Office Manager, Royal College of Paediatrics & Child Health
Mr David Crawford Crown Office and Procurator Fiscal
Dr Julia Egan Professional Advisor for Public Health, Early Years and Children's Services, Scottish Government
Dr Clair Evans Paediatric and Perinatal Pathologist, NHS Greater Glasgow and Clyde
Dr Marjorie Johnston Public Health Registrar, NHS Grampian, seconded to Scottish Government
Dr Martin Kirkpatrick Consultant Paediatric Neurologist, NHS Tayside
DCI Adrian Lawrie Police Scotland
Dr Alyson Leslie School of Education, Social Work and Community Education University of Dundee
Dr John McClure Scottish Cot Death Trust
Dr Jillian McFadzean Consultant in Anaesthesia and Intensive Care, NHS Lothian
Dr John O'Dowd Consultant in Public Health Medicine, NHS Greater Glasgow and Clyde
Dr Rachael Wood Information Services Division
Mrs Mary Sloan Child & Maternal Health, Scottish Government
Mr Anthony Christie Child & Maternal Health, Scottish Government (until October 2013)
Mrs Emily McLean Child & Maternal Health, Scottish Government (from October 2013)

Role and Remit

To establish if there is a need for a national framework to achieve the following:

1. A system for reviewing child deaths across Scotland in a consistent manner in order to reduce the number of [unexplained] child deaths.

2. The provision of clear learning points from the process which links into SG policy and enables quality improvement across all services.


  • Review all existing, available data collected by local and national mechanisms across all agencies involved in the investigation and clinical care up to and after the child's death.
  • Consider who holds the data and who it can be accessed by and how.
  • Review all investigation and audit of child deaths: look at the causes of death and establish what kind of deaths are currently not subject to any formal review process.
  • Map the processes involved in investigating and collating information and who carries out this investigation or review.
  • Understand the process of audit and governance after child deaths and child death review to examine whether learning, practice and policy change is implemented.
  • National and international systems: look at other similar pieces of work being carried out in Scotland and the UK in order not to replicate this work, ie Scottish Paediatric Patient Safety Programme, SUDI process, Clinical Outcomes Review Programme.
  • Consider standards for communication and support to families.

The Steering Group will be expected to:

  • Review and agree the work plan of the project.
  • Oversee the progress of the project and provide support and advice as required.
  • Ensure wide communication of the project within individual networks to ensure buy-in from the wider NHS and other stakeholders.
  • Sign off the final report.

Resources to support this work:

The Child and Maternal Health Division will oversee and provide secretariat support to the group. Other partners (SUDI /ISD) will provide specific time-limited support.


Email: Mary Sloan

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