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.

Chapter 2 Child Death Review Panels

2.1 Consistency of approach is desirable. It is anticipated that the system will likely require adjustment as experience informs the process and thus the issue of flexibility is inherent to the process. A collaborative and learning based approach is considered essential.

2.2 The Steering Group considered that reviews ought to be held within the geographical locality of the relevant Regional Office. Multi-agency input to the review will be essential. A Review Panel member must not be involved in the review of a case with which they were associated. Multi-agency and multi-disciplinary participation is required.

2.3 As stated, it will be the role of the National Resource Centre to support and resource the 3 Regional offices. It will be the role of the Regional Offices to organise, support and provide the secretariat for the Child Death Review Panels (CDRPs).

2.4 It is envisaged that each Regional Office will hold one CDRP each month. It is for the Regional Office, in collaboration with the NRC, to establish CDRPs for their geographical area. The Panels should alternate monthly between reviewing neonatal deaths (up to 28 days of life) and other deaths. Regional Offices may have a pre-Panel meeting with Chairs as they see fit to discuss Panel input, Panel membership, agendas and all matters pertinent to the Panel.

2.5 Reviews should be multi-agency and multi-disciplinary.

2.6 An individual cannot participate in the death review of a child with which they were associated, either professionally or otherwise.

2.7 The proposed model recommends that review Panels for neonatal deaths and deaths of infants in neonatal units may comprise of:

a representative from the 3 Managed Clinical Networks for Neonates
Neonatal Consultant
Local Authority/Social Work representative, depending on circumstances
Primary Care representative
Public Health
One Lay Member from the Third Sector/bereavement services
The Regional Coordinator
The Regional Administrator

Others who may be called on as required, include:

Adult services which may have been involved with the parents
Scottish Ambulance Service.

Flexibility will be required when deciding which deaths are reviewed by a 'neonatal' Panel. For example, it may be more appropriate for babies dying of SUDI before 28 days to be reviewed by the Panel for older children whereas babies dying of complications of prematurity after 28 days, may best be reviewed by the neonatal Panel.

2.8 The proposed model recommends that review Panels for other deaths may comprise of:

Public Health representative
Paediatrician/secondary care representative
Lay member from the Third Sector/bereavement services
Mental health services representative, ie a Child and Adolescent Mental
Health Services lead clinician
Local Authority/Social Work representative
Education representative
Named Person representative
Safeguarder representative
The Regional Coordinator
The Regional Administrator

Others who may be called on as required, include:

Palliative care
Substance misuse services.

2.9 Chairs are to be of a senior, professional level, similar to medical consultant grade or above. They do not require to be of a medical discipline. This position should evoke independence, trust, quality and accountability. The suggested model is that whilst the Chair position ought to be a remunerated position, as is that of the Coordinator and Administrator, the other personnel on a Panel are not. Employing organisations may require to be compensated for the attendance of Panel members at review meetings. All those present ought to receive reasonable travel expenses as required. The precise roles and responsibilities of staff, Chair and Panel members ought to be determined at the implementation stage.

Timescales And Process For Notification

2.10 The National Resource Centre will be informed of child deaths from National Records of Scotland/NHS Central Register/Local Authorities/the Care Inspectorate. Within 2 working days of that notification, the NRC is to inform the Regional Office of the death. Within 7 days from that notification the Regional Office will commence the process of gathering information on the death from relevant agencies and sources. Additionally within that period the Regional Office will identify and record the identity of the Family Engagement Person, as outlined in this report. Thereafter the process of gathering relevant information will proceed. There may be a pre-Panel meeting or further requests for information as appropriate. It is desired that the CDRP will conclude a case within 4 months from initial notification to it. In some cases this timeframe may not be appropriate because of issues such as pathology reports, criminal or civil legal procedures etc. The CDRP may seek further information or adjourn consideration of a case as it sees fit in the circumstances, but a clear record of each consideration of a case, and the outcome of it, must be recorded by the Regional office. The reasons for cases not being concluded within 4 months should be recorded by the regional office and considered by the National Resource Centre.

2.11 Following each Review Panel, the Regional Office will record its conclusions. The Regional Office will retain the conclusions. A partially anonymised version (ie name removed but CHI number retained) will be prepared and sent to the NRC who will use that information for the purposes of collation, consideration, national learning, reporting in an anonymised manner and identifying issues to inform practice and policymaking.

2.12 Whilst local input and knowledge within the Review Panel is essential to understand local service responses and culture, it is equally essential that broader objective input and knowledge should be present to allow a balance and flow of knowledge. Regional Offices will comprise a pool of suitable professionals for CDRPs thus allowing for different experiences and knowledge; and avoiding excessive onerous duties resting on a few.

2.13 Whilst a death may have been the subject of discussion at a SUDI review/significant case review or similar forum, this primary process does not take the place of the CDRP. The CDRP should have the information of previous considerations before it - but it still requires to conduct and conclude on the child death for its own purposes and functions. Some deaths will not have been previously considered and thus a CDRP will be important, and in any event the purposes of the CDRP are different and separate from other processes.

2.14 Uniformity of process, consistency in data outcomes, uniformity of information, and the uniformity of the consideration process of a CDRP is essential. It is known that in the English Child Death Overview Panel (CDOP) system, some CDOPs adapt forms and to varying extent adapt their processes. It is considered that this weakens the trends and scope for learning both locally and nationally from Child Death Reviews. It will be the role of the NRC to manage the uniformity of the process to advance local and national learning.

Learning From Reviews

2.15 National learning from collated information will be an essential component of this model and system. It is seen as a vital element of the process in reducing child deaths, responding to risk and danger, and learning through the deaths of children that there is a robust system for the collation of the results of CDRPs. The clear purpose is to reduce deaths in children and to learn locally and nationally through reviews. The NRC should develop a process to advance this clear intent. This ought to incorporate at least reporting to Scottish Ministers and others each year, on the results of reviews, trends, local and national issues, and on all matters that may affect policymaking and practices.

2.16 The national child death review system will be a novel opportunity for learning in Scotland. This report clearly endorses that and advances such a model. As this will be a new venture it is also reasonably anticipated that lessons may be learnt as the system develops and as the system and CDRPs are implemented. Thus the NRC should have the ability to amend and adjust matters as it sees fit in the interests of the main purposes of the review system. The NRC may require to have a management committee to assist in this process. It is accepted that some flexibility will be required in the operations of CDRPs, however the NRC must ensure that a uniformity of approach and structure is maintained.


2.17 The steering group considered the need for legislation to implement this system and ensure its outcomes. There existed strong feeling within the group that legislation was the only sure method of introducing the system. The delay this would create was also considered and the recommendation is that a Child Death Review process ought to be commenced initially without legislation. It ought to be commenced by way of a "Chief Executive Letter" which issues guidance to health boards regarding policy to be implemented on a non-statutory basis. A similar practice for local authority and other agencies' involvement should also be adopted. As matters evolve, or should the system not commence, then consideration should be given to drawing up a Memorandum of Understanding or a Partnership Agreement with agencies. Legislation would also then be seen as increasingly necessary. The strong desire of the Steering Group is that a Child Death Review process should be instigated with minimal delay.


2.18 The flow chart on the following page is a suggested outline of procedural steps for the operation of Child Death Review Panels. These are not mandatory. It is presented to assist in the understanding of the roles and steps that are recommended. It will be seen that information can flow from a CDRP both toward a local learning setting and toward a national learning setting. The importance for lessons to assist both locally and nationally is a central aim of the process. It is known that in other jurisdictions national learning is not as well developed as is desired. It is sought to avoid that in Scotland. Suggested templates/checklists for running Child Death Review Panels can be seen at Annex 4.

2.19 The suggested domains and criteria the CDRPs should consider are set out at Annex 5.

Child Death Reviews in Scotland flowchart

Child Death Reviews in Scotland flowchart

* For example, requests for information could be sent to the following agencies:

  • Neonatal deaths: maternity hospital; GP; health visiting; school health (if older siblings); social work services; Named Person; Lead Professional; police; voluntary organisations; other as appropriate
  • Child/young person deaths: all of the above (with the exception of maternity unless SUDI); children's/general hospital; youth offending; other as appropriate


Email: Mary Sloan

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