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 1




David Jack, Chair Advocate
Lynsay Allan Scottish Cot Death Trust
Julie-Clare Becher Scottish Neonatal Consultant Group
Amanda Britain University of Dundee Fatality Investigation and Review Studies (Ruby Reviews pilot of child death reviews)
Jen Browning Royal College of Emergency Medicine, Scotland
Jane Byrne Healthcare Improvement Scotland
Kirsty Craig Scottish Government Child and Maternal Health
Sally Egan Child Health Commissioners
Jill Fletcher Scottish Ambulance Service
Ron Gray, on retirement replaced by John O'Dowd Faculty of Public Health
David Green Crown Office and Procurator Fiscal Service
William Guild, on retirement replaced by Scott Cunningham Police Scotland (also representing Family Liaison Officers)
Jacquelyn Jennett Social Work Scotland
Jacqueline Lamb Children in Scotland
Elaine Lockhart Royal College of Psychiatrists Scotland
Martin Kirkpatrick Royal College of Paediatrics and Child Heath (RCPCH)
Kate McKay Scottish Government Senior Medical Officer
Ann McMurray Stillbirth and Neonatal Deaths (SANDS)
Amanda Murphy Paediatric Pathology
Robert Nicol/Kathy Cameron Convention of Scottish Local Authorities (COSLA)
Mary Sloan Scottish Government Child and Maternal Health
Judith Tait Care Inspectorate
Donna Turnbull Scottish Government Child Protection
Rachael Wood Information Services Division, National Services Scotland, NHS Scotland


To establish a National Framework for reviewing child deaths in Scotland which achieves the following:

1. A system for reviewing child deaths across Scotland in a consistent manner in order to reduce the number of child deaths.

2. The provision of clear learning points from the process which links into Scottish Government policy and enables quality improvement across all services.

3. Improve communication with bereaved families.

Objectives for the National Framework

  • Ensure the accurate identification and uniform, consistent reporting of the cause and manner of every child death in Scotland
  • Determine the age range and deaths to include and exclude
  • Improve inter-agency responses in the investigation of child deaths
  • Improve inter-agency responses in the structured review of child deaths
  • Determine who will host (hold) the data, who it can be accessed by and how, IT system to use, core dataset to be captured
  • Determine governance: area of review teams, who is responsible for ensuring a review takes place/identifying cases, arrangements if child dies outwith area or outwith Scotland
  • Determine arrangements for review, including information gathering, confidentiality, venue, recording, standardised forms and agenda
  • Determine standards for communication and support to families to improve the quality, timeliness and method of information sharing with families in the aftermath of a child death and through the review process
  • Identify and manage implications for other family members
  • Identify significant risk factors and trends in child deaths
  • Determine dissemination of learning from reviews, including increasing public awareness and advocacy for the issues that affect the health and safety of children
  • Ensure the process does not replicate other work carried out in Scotland and the UK, i.e., Scottish Paediatric Patient Safety Programme, SUDI process, RCPCH Clinical Outcomes Review Programme.
  • Consider the need for statutory legislation to ensure a national Child Death Review System is put in place.

The Steering Group will be expected to:

  • Review and agree the work plan of the project
  • Attend meetings, provide support and advice as required
  • Contribute to the development of a Child Death Review process by attending meetings and by email between meetings
  • Ensure wide communication within individual networks to ensure buy-in
  • Contribute to and sign off the final report.

Resources to support this work:

The Scottish Government Child and Maternal Health Division will oversee and provide secretariat support to the group. Other partners will be asked to contribute as necessary.


Email: Mary Sloan

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