Child Death Review Process By Paul Wright Designated Doctor for Child Deaths in Surrey Child Death...

Child Death Review ProcessBy Paul WrightDesignated Doctor for Child Deaths in Surrey

Child Death Review Process

Introduction

Why Jason Died


Introduction

• Introduced in Working Together 2006• Statutory since 1st April 2008• Consists of two interrelated processes for

reviewing Child Deaths

Introduction• Introduced in Working Together 2006

• Statutory since 1st April 2008

• Consists of two interrelated processes for reviewing Child Deaths


Introduction 2• 1. Rapid response by a group of key

professionals who come together for the purpose of enquiring into and evaluating each unexpected death of a child

• 2. An overview of all child deaths up to the age of 18 years (excluding both those babies that are stillborn and planned terminations of pregnancy carried out within the law) in the LSCB area, undertaken by a panel

What is an unexpected death?• In this guidance an unexpected death is defined as the

death of an infant or child (less than 18 years old) which:

• Was not anticipated as a significant possibility for example, 24 hours before the death; or

• Where there was a similarly unexpected collapse or incident leading to or precipitating the events which led to the death



Processes for Unexpected Deaths• There are two separate processes followed

unexpected deaths:

• 1. Neonates on Neonatal Unit

• 2. All other Children


Neonatal Deaths

• We consider Neonatal deaths to include all Children born prematurely

• All Children born at term, or near term will follow the normal Child Death Processes

• These Deaths do not initiate a Rapid Response

• Information is collated and reviewed by a co-opted Consultant Neonatologist


Unexpected Deaths in Hospital

• Normal Hospital procedures should take place

• Families should be allocated a member of Hospital Staff to remain with and support them

• Hospital Staff should contact the Coroner

• Hospital Staff should contact the Child Death Review Coordinator to inform them of the Child Death


Unexpected Deaths in the Community

• These Children should normally be taken to an A&E department rather than the mortuary

• There are times when it is clearly inappropriate to take a Child to A&E

• Resuscitation should always be initiated unless clearly inappropriate

• The Child should be examined by a Consultant Paediatrician and a detailed and careful history of the events taken


Unexpected Deaths in the Community 2

• Hospital Staff should contact the Coroner

• A&E should then contact the Child Death Review Coordinator to inform them of the Child Death

• Appropriate support should be offered to the family including where available:• Bereavement Counsellor• Hospital Chaplin• Faith Leader


Rapid Response

• Each LSCB has set up its own procedures for providing rapid response

• Some LSCBs have pooled resources so that rapid response is carried out across a number of LSCBs


Rapid Response inSurrey

• Led by Rapid Response Nurse – Liz Seymour• She will:

• Make contact with the family• Explain to them the Child Death Process• Take the History of events leading to the Death• Present any questions or concerns that they may

have• Will advise the family of where to access support• Feedback to the family any results of the

investigation


Rapid Response inSurrey 2

• Rapid Response should take place within a week of the death

• However this can be delayed if the family wish it to be

• There are occasions when Rapid Response is inappropriate


Child Death Review

• This is a set review to bring together information about the events leading up to a Child’s death

• It is a multi-professional meeting. Those who are generally invited include:

• Named Nurse• General Practitioner• School Nurse/ Health Visitor• Hospital Paediatricians


Child Death Review 2

• Other Professionals invited:• Hospital Nursing Staff• Tertiary Consultants• Social Care• Police• School• Educational Psychologist• Ambulance Staff• Coroner’s Officer

• Other Professionals may be invited dependant on review


Child Death Review 3• Aims of the Review:

• To look at the events leading to the Child’s death• To look and see if any changes in management

may have prevented the death• To get a holistic picture of the Child• To look at the support the family are receiving• To look at the preventability of the death• To categorize the death• To consider referral for an SCR


Preventability

• Government Statistics consider 3 categories which are reported on at the end of the year:

• Unpreventable

• Partially Preventable

• Preventable


Categories of Deaths• This Classification is hierarchical: where more

than category could reasonably be applied, the highest up the list should be marked

• 1. Deliberately inflicted injury, abuse or neglect

• 2. Suicide or deliberate self-inflicted harm• 3. Trauma and other external factors• 4. Malignancy• 5. Acute Medical or Surgical Condition• 6. Chronic Medical Condition


Categories of Deaths 2

• 7. Chromosomal, Genetic and Congenital anomalies

• 8. Perinatal/ neonatal event• 9. Infection• 10. Sudden Unexpected, Unexplained

death

• Often categorization of the death has to wait until the inquest has taken place


Child Death Overview Panel• This is a Statutory Panel which meets every 2

months in Surrey

• It is chaired by an Independent Chair

• It is a multi-professional panel


Child Death Overview Panel 2• Representatives include:

• Health• Social Care• Police• Ambulance• Coroner’s Office• Voluntary Sector (CHASE Hospice)• Public Health• Risk Manager, NHS Surrey


CDOP Functions

• CDOP has many functions which are defined in Working Together 2010

• These include:• Determining Preventability on all deaths• Collecting and collating the minimum data set on

each child• Evaluating the data set and identifying lessons to

be learnt or issues of concern


CDOP Functions 2

• Reviewing specific cases in detail• Referring to the Chair of LSCB if there are grounds

to undertake further enquiries e.g. SCR• Monitoring support and assessment services to the

families of children who have died• Identifying any Public Health issues• Co-operating with regional or national initiatives


Surrey Child Deaths 2011 - 2012

Surrey Children Non-Surrey Children

Total Child Deaths

<1 month 31 18 49

1 month to 1 year 11 4 15

1 year to 4 years 4 3 7

5 years to 9 years 3 1 4



Total 56 27 83


Resident Surrey Child Deaths 2011 - 2012

Male Female

<1 month 17 14

1 month to 1 year 5 6

1 year to 4 years 2 2

5 years to 9 years 2 1



Total 30 26


Unexpected Surrey Child Deaths 2011 - 2012

Male Female Total

<1 month 1 1 2

1 month to 1 year 3 4 7

1 year to 4 years 2 1 3




Total 8 9 17


Child Death Reviews 2011 -2012• 17 Cases reviewed between April 2011 and March

2012

• Of these:• 4 Sudden Unexpected Death in Infancy• 4 acute medical or surgical conditions including 2

SUDEPs• 3 infections• 1 drowning• 1 equipment failure• 4 awaiting categories


Child Death Reviews 2011 -2012

• 3 Deaths were referred to the Serious Case Review Group

• Of these:

• One went to Serious Case Review• One to Case Review• One did not proceed


Child deaths 2011-2012 by category and sex

Category of death Male Female

Deliberately Inflicted injury, abuse or neglect 0 0

Suicide or deliberate self inflicted harm 0 0

Trauma and other external factors 2 0

Malignancy 2 0

Acute medical or surgical condition 3 3

Chronic medical condition 1 2

Chromosomal, genetic and congenital abnormalities 2 3

Perinatal / Neonatal event 10 7

Infection 2 0

Sudden unexpected, unexplained death 2 3

Awaiting categorisation (9: Neonatal, 3: waiting for post mortem results)

6 8

Total 30 26


Preventable Deaths

• 6 Preventable Deaths between April 2011 and March 2012

• 1 died overseas• 2 died of SIDS although evidence of co-sleeping and

drug/ alcohol use• 1 drowning in the bath• 1 due to overwhelming infection not recognized by

medical professionals• 1 due to equipment failure



Learning

• Learning points to be considered:

• There have been a number of deaths associated with co-sleeping, and with a history of alcohol and drug use. CDOP feels that a co-sleeping campaign is required

• There are still issues about the notification of deaths in children who are not taken to A+E, i.e. the child is pronounced dead at the scene

• Listening to the parents about feeding problems in newborns


Learning 2• Additional Learning Points:

• A need to examine neonatal deaths in detail

• Lack of minimum standards for laboratory investigations after child deaths in Surrey

Thank you

Child Death Review Process By Paul Wright Designated Doctor for Child Deaths in Surrey Child Death...

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