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 4: Child Health Commissioner responses

In May 2013, the Child Health Commissioners within each territorial Health Board in Scotland were sent a questionnaire survey with regards to child death review processes in their area. 12 out of the 14 territorial NHS Boards participated in this Child Death Review Audit. The questions are below with a summary of the responses.

Does your Health Board area have a child death review group?

3 Boards do have a child death review group

8 Boards do not

1 Board was unsure.

Comments from Boards who said no or were unsure:

  • 2 Boards reported not formally called that but have a multi-disciplinary process
  • One Board is developing a morbidity/mortality review meeting within paediatrics which will fulfil some of the roles of such a group: another reported all hospital deaths are reviewed through a mortality review process
  • One Board has a Significant Clinical Incident Review Group, all paediatric deaths in the children's hospital are reviewed by the Chair of PRAM (Paediatric review and audit of mortality) and any unexpected paediatric deaths trigger a review under Significant Clinical Incident process, the Board's child protection forum examines Significant Case Reviews where there is a child protection issue and clinical governance groups examine Datix reports
  • One Board reported cases are looked at individually by the paediatric named consultant
  • 4 Boards reported child protection committees would instigate reviews where appropriate

If yes can you describe its role, remit and membership?

1 Board reported annual multi-disciplinary childhood mortality meeting to review all post-neonatal deaths in infancy and childhood

3 Boards reported meetings took place to learn lessons

1 Board reported the remit was to review any unexpected child death in relation to child protection.

1 Board reported role is to ensure governance of child protection.

2 Boards reported Significant Incident procedure would be followed.

1 Board reported PRAMS monthly meetings - cases are selected and presented for discussion. Chair of PRAMS also leads the local risk group and links PRAMS' identified issues into the risk agenda.

1 Board reported its perinatal mortality group is a multi-disciplinary child death review group.

Membership varied - medical staff, paediatricians; head of paediatric services; paediatric nursing, A&E, anaesthetic staff; regional PICU colleagues, child protection, pathologist, clinical directors, consultant relevant to specialty, clinical risk manager, critical incident response group involvement, other members identified relevant to individual cases

Do you have a Paediatric review and audit of mortality (PRAM) in place?

8 Boards have a PRAM in place

4 Boards do not

Within the Paediatric setting, do any other reviews occur following a child death?

Boards reported other reviews occur when appropriate:

  • SUDI (Sudden Unexpected Death in Infancy) reviews
  • SUDiC (Sudden Unexpected Death in Children)
  • Child Death Review processes
  • Child protection procedures
  • Perinatal reviews
  • Significant case review/event, Adverse Event Review
  • PICU reviews
  • Individual service reviews
  • DATIX process
  • Regular departmental/multi-professional meetings, multi-disciplinary/multi-agency reviews, de-brief meetings, peer review meetings
  • Maternity Services Clinical Governance Forum
  • Reported via MBRRACE

If yes can you describe these in terms of their roles, remits and membership?

Role and remit as per:

  • Child protection procedures
  • SUDI/SUDiC protocols
  • Perinatal mortality meetings
  • Child death review process
  • Significant case review process/significant event analysis meeting to discuss learning points and put action plans in place
  • De-brief meetings for staff catharsis and fact-finding to inform significant event review
  • Feedback from PICU
  • Establish events and identify/share learning points across agencies

Membership includes staff concerned, SUDI paediatrician, GP, pathologist, paediatric and obstetric consultants, associated nursing and midwifery staff, obstetricians, neonatal nurses, multi-disciplinary, consultant who leads on quality and safety, emergency medicine, anaesthetics, PICU, primary care staff, social workers, education, police, procurator fiscal, public health

Out with the Paediatric setting are you aware of any specific reviews occurring following a child death, for example in Psychiatry following a child suicide?

6 Boards reported specific reviews occurred, eg Significant Clinical Incident Review Group, Significant Case Reviews for child protection, Initial Case Review or Serious Case Review for child on child protection register/LAC or known child protection concerns, reviews led by specialist children's services, reviews led by the Ambulance Service, CAMHS Mental Health Critical Incident/Pathway following Suicide/Unexplained Death reporting processes.

4 Boards reported no specific reviews occurred

1 Board reported no child suicides

If yes can you describe these in terms of their role, remit and membership?

Adverse significant event policy, significant case review if potential child protection issue, Mental Health Critical Incident Review, family and community support, bereavement counselling, Critical Incident Review, Suicide Review Policy

Role and remit as per Scottish Government guidance for Child Protection.

Membership includes lead clinician determined by the circumstances, CAMHS, psychology, educational psychology, Associate Medical Director, Clinical Director, General Manager

Are child deaths which are "expected" (for example following a long illness) routinely reviewed in your Health Board?

4 Boards reported "expected" child deaths are routinely reviewed

6 Boards reported they are not

1 Board was unsure and 1 Board was unsure for acute services.

If yes can you describe these reviews in terms of their role, remit and membership if not already covered above?

Annual mortality meeting, as per Child Death Review process, PRAMS, Significant Event Analysis meetings, exploring need to set up Child Death Review Group.

Are there any multi-agency groups (involving Health, Social Work, the Police and/or others) which review child deaths?

9 Boards reported yes

2 Boards reported no

If yes can you describe these in terms of their role, remit and membership if not already covered above?

Child protection committee review sub-group, significant/serious case reviews, child protection committees, formal meetings to discuss child protection deaths and SUDI.

Membership can be multi-discplinary including health, social work, police, lead paediatricians for child protection

Does your Health Board area have any other processes in place to review child deaths not covered here?

3 Boards reported yes

8 Boards reported no

If yes, can you describe these in terms of their role, remit and membership?

Potentially as part of HSMR (Hospital Standardised Mortality Ratios) patient safety programme, other mechanisms such as significant untoward incident investigation, discussed at Clinical Governance and Risk Management Group, SUDI

Membership of the groups includes lead paediatrician, pharmacist, dental, GP, Scottish Patient Safety Programme representative, Out-of-Hours, paramedics, social work, A&E, primary/secondary care, pathologist, SUDI paediatrician/review officer


Are the lessons identified from any of the reviews listed above disseminated and acted upon by the relevant agency involved?

10 Boards reported yes adding:

  • As per child death review process and Child Protection Committee review subgroup
  • definite room for improvement
  • reported widely and action plans drawn up and reviewed to ensure implementation
  • recommendations circulated to specialist children's service managers to discuss with staff and implement
  • actions implemented by child protection groups
  • recommendations reviewed to include consideration of wider learning, action plans generated and tracked for completion
  • paediatric patient safety bulletin
  • reports reviewed by local quality improvement teams, child protection or serious incident reports considered by Board Joint Management Team and followed up. Actions form an Action Plan
  • Learning from Significant Case Reviews shared by relevant agency. Recommendations discussed at child protection executive group where actions will be agreed

Are you aware of lessons being shared with other areas/agencies after any of the reviews listed above?

7 Boards reported yes

1 Board reported no

1 Board was unsure

2 Boards reported yes but not for all reviews

Lessons were shared with Child Protection Committees and CPC Review subgroup, Clinical Management Teams, Multidisciplinary Teams

If yes, which reviews does this occur for, how are lessons shared and who are they shared with?

  • SUDI, occasionally other deaths if significant point identified
  • SUDI learning points correlated and disseminated via Healthcare Improvement Scotland Health takes the lead role in reviewing all child deaths, anonymised report discussed at Child Protection Committee review subgroup. Learning shared with staff involved
  • As part of Child Protection Committee process
  • Recommendations circulated to Director of Women and Children's Directorate, Child Protection, Director and Clinical Director of sector in which incident occurred
  • Multi-agency or multi-disciplinary reviews. Significant case review lessons shared with local authorities or multi-agency
  • According to individual circumstances.
  • Newsletter for GPs
  • Shared via Clinical Governance and Risk Management Group meetings
  • Child protection reviews shared with social work and police following child protection guidelines and procedures
  • Serious Case Review findings/recommendations shared with Healthcare Governance and Risk Management committee.
  • Procurator Fiscal and frontline staff may also be appraised
  • Departmental meetings
  • Child protection training updated and specific staff group training needs identified and training programmes implemented where required
  • Lessons shared via Child Protection Committee for dissemination to key staff within each agency.

Do you feel lessons learned from child deaths are effectively disseminated to other areas and agencies (for example changes are made in response to learning points identified)?

6 Boards said yes

1 Board said no

2 Boards were unsure

One Board reported Yes for specialist children's services, currently being audited for child protection and no, could improve, for acute services.

If yes, can you describe for which reviews this occurs and give examples as to what enables the process to be effective?

  • One Board reported learning lessons from avoidable accidents eg dangers of loops on blinds, co-sleeping and raising awareness or making changes.
  • One Board reported all child deaths were reviewed or discussed by the Child Protection Committee review sub-group. Lessons learned/actions taken included improving the communication pathway
  • One Board reported within specialist children's services, recommendations are circulated within the Board and an audit of implementing recommendations is in development.
  • Three Boards reported lessons from Significant Case Reviews are shared and action plans developed - multidisciplinary.
  • One Board reported lessons learned from suicide reviews are circulated to Operational Management Groups who then consider and agree how best to implement/disseminate learning. Child Protection Serious Case Reviews are shared with all agencies, action plans are monitored and reviewed.
  • One Board reported following a high profile review, its procedure for the Unseen Child and failure to attend appointments had been reviewed.

If lessons are not shared/ not effectively shared, do you feel that there is a need for a process to ensure that this does occur?

9 Boards responded yes with comments:

  • Useful to have central collation of findings so patterns can be identified
  • Ensure support in place for the family and timely identification of any child protection concerns
  • Multiagency learning points, for child protection and other child deaths, eg those with chronic health needs often had social care involvement. Are we good at changing things to prevent children dying in accidents?
  • Joint debriefs help with learning and with supporting staff as well as improving feedback to parents. Child deaths would benefit from SUDI approach - families appreciate an agreed pathway for information and support that indicates they are not alone and offers hope that others have survived the loss of a child
  • Standardised process would be welcome
  • Learning and improvement to better manage risk
  • A process to ensure learning points and actions plans are acted on to potentially improve children's services and to facilitate feedback/counselling with parents would be helpful
  • There may be value in an overarching group to ensure that everything that could have been done has been done across all relevant agencies
  • A nationally agreed process would be helpful.

1 Board was unsure

Finally, do you have any comments not covered by the questions above? In particular do you have any comment on the proposal to consider setting up a Child Death Review process in Scotland?

Comments included:

  • Strongly support CDR process - to set best practice regarding inter-agency analysis of all child deaths, not only those where significant case reviews are instigated for child protection
  • A nationally agreed procedure and standards would be helpful
  • There should be local and national components
  • A CDR process in Scotland would potentially provide significant learning points for all agencies involved which would improve children's services in Scotland
  • The process could review expected and unexpected deaths, and also look at child deaths in the community which involve the Child Protection team
  • People who know the family well should be involved
  • The CDR process in the United States could be useful in Scotland
  • Would welcome guidance on involving families in CDR process
  • CHAS holds debrief sessions - currently discussing models of care with them. CHAS should be involved
  • Consideration should be given to potential effect of the Managed Clinical Networks that may result in children dying in Health Board areas other than their place of residence - this could affect who is involved in the review of deaths and the legal processes
  • The needs of families who suffer the death of an adolescent may be relevant, especially in relation to suicide and risk behaviour but the death may present to adult services
  • Essential to have administrative resource allocated to ensure the process works effectively
  • Needs to be a balance between child protection procedures and other aspects - SUDI work could be taken into account


Email: Mary Sloan

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