Child Death Reviews: Scottish Government Steering Group Report

The report of the Scottish Government Child Death Reviews Steering Group setting out recommendations for establishing a national child death review system in Scotland.

Annex 5

Analysis Proforma

The proforma should be used by the Child Death Review Panel (CDRP) to:

  • Evaluate information about the child's death;
  • Identify lessons to be learnt;
  • To inform an understanding of all child deaths at a national level.

The CDRP meeting participants should analyse any relevant environmental, extrinsic, medical or personal factors that may have contributed to the child's death under the headings below.

Domain - Factors intrinsic to the child

Include any known health needs; factors influencing health; development/educational issues; behavioural issues; social relationships; identity and independence; abuse of drugs or alcohol; note strengths and difficulties

[Factors include: acute/sudden onset illness; chronic long term illness (asthma/epilepsy/diabetes/other chronic illness); disability or impairment (learning disability/motor impairment/sensory impairment/other disability or impairment); emotional/behavioural/mental health condition; allergies; alcohol/substance misuse by the child]

Domain - Factors in the child's family and social environment

Include family structure and functioning; including parental abuse of drugs or alcohol; wider family relationships; housing; employment and income; social integration and support; community resources; note strengths and difficulties

[Factors include: emotional/behavioural/mental health condition in parent or carer; alcohol/substance misuse; smoking in household; smoking during pregnancy; housing, domestic violence; co-sleeping; bullying; gang/knife crime; pets/animal assault; consanguinity]

Domain - Factors in the child's wider and physical environment

Include issues around provision of basic care; health care (including antenatal care where relevant); safety; emotional warmth; stimulation; guidance and boundaries; stability; note strengths and difficulties

[Factors include: poor parenting/supervision; child abuse/neglect]

Domain - Factors in relation to service provision/delivery

Include any identified services (either required or provided); any gaps between child's or family member's needs and service provision or delivery; any issues in relation to service provision or uptake

[Factors include: access to health care; poor medical intervention; poor surgical intervention]

The CDRP should analyse any relevant environmental, extrinsic, medical or personal factors that may have contributed to the child's death under the following headings.

For each of the four domains below, determine different levels of influence (0-3) for any identified factors:

0 - Information not available
1 - No factors identified or factors identified but are unlikely to have contributed to the death
2 - Factors identified that may have contributed to vulnerability, ill-health or death
3 - Factors identified that provide a complete and sufficient explanation for the death

This information should inform the learning of lessons at a local and national level.

The CDRP should categorise the likely/cause of death using the following schema.

This classification is hierarchical: where more than one category could reasonably be applied, the highest up the list should be marked.

Category Name & description of category Tick box below
1 Deliberately inflicted injury, abuse or neglect
This includes suffocation, shaking injury, knifing, shooting, poisoning & other means of probable or definite homicide; also deaths from war, terrorism or other mass violence; includes severe neglect leading to death
2 Suicide or deliberate self-inflicted harm
This includes hanging, shooting, self-poisoning with paracetamol, death by self-asphyxia, from solvent inhalation, alcohol or drug abuse, or other form of self-harm. It will usually apply to adolescents rather than younger children.
3 Trauma and other external factors
This includes isolated head injury, other or multiple trauma, burn injury, drowning, unintentional self-poisoning in pre-school children, anaphylaxis & other extrinsic factors. Excludes Deliberately inflected injury, abuse or neglect. (category 1).
4 Malignancy
Solid tumours, leukaemias & lymphomas, and malignant proliferative conditions such as histiocytosis, even if the final event leading to death was infection, haemorrhage etc.
5 Acute medical or surgical condition
For example, Kawasaki disease, acute nephritis, intestinal volvulus, diabetic ketoacidosis, acute asthma, intussusception, appendicitis; sudden unexpected deaths with epilepsy.
6 Chronic medical condition
For example, Crohn's disease, liver disease, immune deficiencies, even if the final event leading to death was infection, haemorrhage etc. Includes cerebral palsy with clear post-perinatal cause.
7 Chromosomal, genetic and congenital anomalies
Trisomies, other chromosomal disorders, single gene defects, neurodegenerative disease, cystic fibrosis, and other congenital anomalies including cardiac.
8 Perinatal/neonatal event
Death ultimately related to perinatal events, eg sequelae of prematurity, antepartum and intrapartum anoxia, bronchopulmonary dysplasia, post-haemorrhagic hydrocephalus, irrespective of age at death. It includes cerebral palsy without evidence of cause, and includes congenital or early-onset bacterial infection (onset in the first postnatal week).
9 Infection
Any primary infection (ie, not a complication of one of the above categories), arising after the first postnatal week, or after discharge of a preterm baby. This would include septicaemia, pneumonia, meningitis, HIV infection etc.
10 Sudden unexpected, unexplained death
Where the pathological diagnosis is either 'SIDS' or 'unascertained', at any age. Excludes Sudden Unexpected Death in Epilepsy (category 5).

The Panel should categorise the 'preventability' of the death - tick one box.

Preventable child deaths are those in which modifiable factors may have contributed to the death. These are factors defined as those where, if actions could be taken through national or local interventions, the risk of future child deaths could be reduced.

Modifiable factors identified The Panel have identified one or more factors, in any domain, which may have contributed to the death of the child and which, by means of locally or nationally achievable interventions, could be modified to reduce the risk of future child deaths
No Modifiable factors identified The Panel have not identified any potentially modifiable factors in relation to this death
Inadequate information upon which to make a judgement. NB this category should be used very rarely indeed.


Email: Mary Sloan

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