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 6 Recommendations

These recommendations are submitted on the basis that Scottish Ministers, in 2014, accepted the recommendation of the Child Death Reviews Working Group report - that Scotland should introduce a national Child Death Review System.

The Child Death Reviews Steering Group, with reference to the contents of this report, respectfully recommends:

1 A Scottish national child death reviews system should be established comprising one National Resource Centre (NRC), along with 3 Regional Offices, based in the North, West and East areas of the country.

2 This should be an independent system - independent of existing structures, though it may be hosted within existing infrastructure.

3. Child Death Reviews should be conducted at Child Death Review Panels (CDRPs) to review the deaths, of all live born children up to the date of their 18th birthday; and for care leavers in receipt of aftercare or continuing care at the time of their death, up to the date of their 26th birthday.

4. National Records of Scotland/NHS Central Register/Local Authorities/the Care Inspectorate should be commissioned to inform the NRC of the deaths of said persons registered in Scotland.

5. The review system should review deaths of children and young people, who die in Scotland and who are resident in Scotland. Arrangements should be put in place for a Scottish child dying outside Scotland, and for a child dying in Scotland who does not reside in Scotland.

6. Reviews should be conducted in a collaborative manner and with a learning approach. Reviews will not be to establish professional blame or responsibility. Reviews will be to consider modifiable and preventable factors, with the purpose of learning lessons, locally and nationally, to prevent avoidable deaths.

7. A Family Engagement Person should be appointed in all cases for the purposes outlined in this report. That appointment and engagement should commence at the start of the review process. Families should not attend review Panels but should be engaged in the process through the Family Engagement Person.

8. Child Death Review Panels may meet and conduct the review process in accordance with the suggested contents of this report.

9. Review Panels should be multi-agency and multi-disciplinary.

10. Uniformity of process, consistency in data outcomes, uniformity of information collection, and the uniformity of the consideration process of a CDRP will be essential.

11. Child Death Review Panels should not duplicate work from other review structures, eg hospital mortality or morbidity reviews, neonatal reviews, SUDIs, FAIs etc. There is a need for an initial process at local level to consider all deaths to inform Child Death Review Panels. Child Death Review Panels should endeavour to use all available information, including the findings of other review mechanisms, in the conduct of their review.

12. The review process should commence within 7 days of the notification to the Regional Office. The Review Panel should convene and, where possible, conclude within 4 months from the commencement of the process. It is understood that some circumstances will prevent that timeframe being fulfilled in which cases the reasons for delay beyond 4 months should be recorded and considered by the National Resource Centre.

13. Information could be notified, collected and retained in a small number of documents, such as in the Forms 1, 2, and 3 outlined in this report.

14. The analysis of potential influential factors to a death may follow, among other factors, the considerations of the domain factors and categorisations, outlined in this report.

15. Modifiable or preventable factors from deaths should be recorded, considered and acted upon locally and nationally. This report outlines how that may be done.

16. It is recommended that adapting an existing IT system is a desirable, and ought to be the favoured, approach. This is likely to be the most economic and compatible approach.

17. The proposed system suggests 9 full time employment positions, with Panel Chairpersons being remunerated, on a pro rata basis.

18. Funding, as outlined in this report, should be made available to proceed with the Scottish Ministers' acceptance that Scotland should introduce a national Child Death Review System.

19. Legislation is not the desired method of instigating a Child Death Review system, due to likely issues of delay. A "Chief Executives' letter", used for implementing non-statutory policies is preferred, at this stage. A similar practice for local authority and other agency involvement should be adopted.

20. The process of data collection, and the data that is collected, on the death of a child and young person, ought to become more uniform, across the numerous Health Boards and agencies involved.

21. A Management Committee for the proposed NRC ought to be constituted to establish the NRC, to act upon its objectives, and to be accountable for its actions, objectives and budget.


Email: Mary Sloan

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