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.

Existing review processes and surveillance systems in Scotland

17. Currently there are a variety of processes and mechanisms (statutory, regulatory, investigative, procedural, internal to agencies and multi-agency, formal and informal). These include:

Local hospital mortality reviews

18. There are numerous and varied informal and formal mechanisms that operate in different Health Board areas, to review a child's death. There is however no consistent process across Scotland, and no consistent multiagency groups which review all child deaths. Reviews that do take place may or may not reach conclusions about lessons to be learned, but sharing of those lessons more widely seems to be limited.

19. There are some groups of children where a process is more established. Perinatal morbidity and mortality meetings have run for many years and some paediatric units review all in-hospital deaths. These reviews are limited because they impact only on hospital health-care staff and there is limited evidence of sharing of lessons learned across health services.

Multi-agency child death reviews

20. There are some multi-agency review processes but these are confined to particular groupings of children. Significant Case Reviews are carried out by the local Child Protection Committees, after serious harm or death caused by child abuse. However not every child death where child protection concerns were known to have existed is subject to a Significant Case Review in Scotland. Infants who have suffered 'sudden and unexpected deaths in infancy' (SUDI) are reviewed through a multiagency process. NHS Boards have a responsibility to ensure that the meeting takes place with the appropriate professionals and that the SUDI Review summary sheet is completed and sent to Healthcare Improvement Scotland (HIS). The Care Inspectorate has a statutory duty to carry out reviews into deaths of Looked After Children and can make recommendations for other services, although these may not be implemented.

Procurator Fiscal Inquiries

21. At a national and regional level there are investigations by the Procurator Fiscal after certain deaths under the aegis of the Scottish Fatalities Investigations Units (SFIU).

22. The Procurator Fiscal may instruct expert opinion and will review all information relevant to the death whether from the Care Inspectorate or other sources. While there is no formalised process for dissemination of lessons learned such information would be provided to the organisations involved.


Email: Mary Sloan

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