Child Death Review Report : Scottish Government Child Death Review Working Group

SCOTTISH GOVERNMENT CHILD DEATH REVIEW WORKING GROUP

Consideration of a child death review system in Scotland: Report on findings

Executive Summary

The death of any child is a tragedy for families, and society would expect that the reasons for that death would be explored and lessons learned to reduce the chance of further deaths in children. Scotland has a considerably higher mortality rate in children and young people, in comparison to many other countries in Western Europe. A number of different formal and informal mechanisms already exist to examine some childhood deaths but there is considerable geographical variation across Scotland and mechanisms are often designed only for certain categories of childhood deaths. Some mechanisms produce epidemiological data that would be helpful in learning lessons at operational and strategic levels, locally and nationally, but data gathering is poorly coordinated.

The Scottish Government set up a Child Death Review Working Group to explore current practice in Scotland and to consider whether Scotland should introduce a collaborative multi-agency system for reviewing the circumstances surrounding the death of a child. Data generated from these reviews would inform policy and contribute to the prevention of child deaths in Scotland in the future.

Recommendation

The Working Group recommends that Scotland should introduce a national Child Death Review System which would:

• systematically review each death in a multi-agency forum. Any local learning would be implemented amongst relevant professionals and services. These reviews should be timely, appropriate and sensitive to the needs of bereaved families.
• collate a uniform data-set relevant to each child death for national analysis to inform national multi-agency learning and aid the development of national policy and
• identify factors which may reduce preventable childhood deaths.

In order to achieve this, a national multi-agency Steering Group should be established to make recommendations to the Scottish Government on implementation. The Steering Group should take into account pilot work currently underway which will inform the way the system is delivered.

The views and needs of families are of paramount importance in this process.