Child Death Reviews: Scottish Government Steering Group Report

Annex 3

NOTIFICATION AND DATA COLLECTION FORMS

Data items for Child Death Review forms		Form 1	Form 2	Form 3
Data item	Coding structure/comments	Initial notification	Information gathering template	Summary review output data
Child identifiers and demographics
CDR unique case reference number			√	√
CHI number		√	√	√
NRS death registration identifiers		√		√
NRS registration district		√		√
NRS registration year		√		√
NRS entry number		√		√
First forename		√	√
Second forename		√	√
Surname		√	√
Previous forename		√	√
Previous surname		√	√
Date of birth	DD/MM/YYYY	√	√	√
Gender	M/F	√	√	√
Address of usual residence		√	√
Postcode of usual residence		√	√	√
Alternative postcode	Eg if child lives between two homes or has recently moved	√	√	√
Country of residence		√
Area of usual residence	NHS Ayrshire & Arran			√
	NHS Borders			√
	NHS Dumfries & Galloway			√
	NHS Fife			√
	NHS Forth Valley			√
	NHS Grampian			√
	NHS Greater Glasgow & Clyde			√
	NHS Highland			√
	NHS Lanarkshire			√
	NHS Lothian			√
	NHS Orkney			√
	NHS Shetland			√
	NHS Tayside			√
	NHS Western Isles			√
	Rest of UK			√
	Outwith UK			√
Country of birth		√	√	√
Length of time in Scotland prior to death	YY/MM		√	√
Ethnicity	See code list	√	√	√
At the time of death, was the child:			√	√
Member of a travelling family	Y/N		√	√
Unaccompanied asylum seeker	Y/N		√	√
Member of asylum seeking family	Y/N		√	√
Recognised as homeless	Y/N		√	√
Looked after child	Y/N		√	√
On child protection register	Y/N		√	√
Respondent identifiers		√
Individual registering the death		√
Forename		√
Surname		√
Address		√
Postcode		√
Date of registration	DD/MM/YY	√
Doctor certifying the death		√
Forename		√
Surname		√
Business address		√
Business contact telephone number		√
Consultant responsible for deceased as a patient		√
Registered GP		√
Forename		√
Surname		√
Surgery address		√
Each individual completing information gathering template			√
Forename			√
Surname			√
Job title			√
Place of work			√
Address			√
Postcode			√
Tel			√
Email			√
Date of completion	DD/MM/YY		√
Circumstances of the death
Type of death	Neonatal death		√
May trigger additional type specific data collection forms.	Death of a child with a life limiting condition		√
	SUDI		√
	Road traffic accident		√
	Drowning		√
	Fire/burns		√
	Poisoning		√
	Other non-intentional injury		√
	Substance misuse		√
	Apparent homicide		√
	Apparent suicide		√
Death expected ie death anticipated as a significant possibility in 24 hours before the death (or before the collapse that precipitated the events leading to death)	Y/N		√
Medical certificate of cause of death issued	Y/N	√	√
Registered cause of death		√	√
Ia		√	√
Ib		√	√
Ic		√	√
Id		√	√
Ie		√	√
Death referred to Procurator Fiscal?	Y/N	√	√
Post mortem intended or carried out?	Y/N	√	√
Post mortem carried out?	Y/N		√
Other reviews conducted on death (concluded/ongoing)			√
Critical incident review	Y/N		√
SUDI review	Y/N		√
Significant case review	Y/N		√
Fatal accident inquiry	Y/N		√
Other, eg Adverse Event Review, Medical certificate of cause of death (MCCD)?			√
Cause of death - provisional description			√
Circumstances of death - provisional description			√
Date of death	DD/MM/YYYY	√	√
Time of death	00.00-24.00	√	√
Age at death	YY/MM	√	√
Place of death - address		√	√
Place of death - postcode		√	√
Place of death - type	Neonatal unit		√
	A&E		√
	Paediatric ward		√
	ICU/HDU		√
	Psychiatric hospital/unit		√
	Hospice		√
	Family home		√
	Other private residence		√
	Residential care setting		√
	School/nursery		√
	Public place		√
	Outwith Scotland		√
	Other		√
	Not known		√
Date of event leading to death			√
Time of event leading to death			√
Place of event leading to death - address	If applicable eg onset of acute medical condition or injury that lead to the death		√
Place of event leading to death - postcode			√
Place of event leading to death - type			√
Child's medical history			√
Gestation at birth	WW (completed weeks)		√
Birthweight	In gms		√
Multiple birth	Singleton		√
	Twin		√
	Triplet or more		√
Perinatal issues			√
Developmental issues/disability			√
Physical health issues			√
Mental health issues			√
Child on medication at time of death	Free text		√
Alcohol or substance misuse			√
Summary of factors intrinsic to the child that are relevant to the death	Free text		√
Child's educational history			√
Child's education/occupation status	Not yet in education		√
	Early education and childcare		√
	School		√
	Further/higher education		√
	Left education - employed		√
	Left education - unemployed		√
School/nursery attended	Name, address, postcode		√
Family/carers and household			√
Number of adults living in child's usual place of residence			√
For each adult			√
Date of birth/age	DD/MM/YY or YY		√
Gender	M/F		√
Relationship to child			√
Health or social issues?	Eg physical health, mental health, disability, alcohol or substance misuse		√
Number of children living in child's usual place of residence			√
For each child			√
Date of birth/age	DD/MM/YY or YY		√
Gender	M/F		√
Relationship to child			√
Health or social issues?	Eg physical health, mental health, disability, alcohol or substance misuse		√
Other carers living elsewhere			√
For each carer			√
Date of birth/age	DD/MM/YY or YY		√
Gender	M/F		√
Relationship to child			√
Health or social issues?	Eg physical health, mental health, disability, alcohol or substance misuse		√
Other siblings living elsewhere			√
For each sibling			√
Date of birth/age	DD/MM/YY or YY		√
Gender	M/F		√
Relationship to child			√
Health or social issues?	Eg physical health, mental health, disability, alcohol or substance misuse		√
Was the child ever looked after or on the child protection register?	Y/N		√
Have any siblings ever been looked after or on the child protection register?	Y/N		√
Summary of factors in the child's family, household, and wider social environment that are relevant to the death	Free text		√
Services involved with child			√
Were the following services involved with the child at the time of death (or during the final illness)?	Primary health care		√
	Secondary health care		√
	CAMHS		√
	Hospice		√
	Early education and childcare		√
	Education		√
	Social work		√
	Scottish Children's Reporter Administration		√
	Other		√
Summary of factors relating to the services being provided to the child/family that are relevant to the death	Free text		√
Delivery of review
Date of CDR	DD/MM/YYYY			√
Duration	H, MM			√
Agencies/specialties represented at review meeting	Primary health care			√
	Neonatology			√
	Paediatrics			√
	Child and adolescent mental health			√
	Public health			√
	Ambulance service			√
	Other healthcare			√
	Police			√
	Fire service			√
	Procurator Fiscal			√
	Social work			√
	Early education and childcare			√
	Education			√
	Family representative			√
	Other			√
Family involvement in review	Submitted written information			√
	Review findings to be provided to family in written format			√
	Review findings to be discussed with family			√
Information gathering template available from	Primary health care			√
	Secondary health care			√
	CAMHS			√
	Hospice			√
	Early education and childcare/Education			√
	Social work			√
	Other			√
Outcome of review				√
Cause of death - final description	Free text			√
Cause of death - classified	Deliberately inflicted injury, abuse or neglect			√
	Suicide or deliberate self-inflicted harm			√
	Trauma and other external factors			√
	Malignancy			√
	Acute medical or surgical conditions			√
	Chronic medical condition			√
	Chromosomal, genetic and congenital anomalies			√
	Perinatal/neonatal event			√
	Infection			√
	Sudden unexpected, unexplained death			√
Factors that may have contributed to the child's death	Categorise each specific category marked 0-3 as
	0 No information available
	1 No factors likely to have contributed to death
	2 Factors identified that may have contributed to death
	3 Factors identified that provide a complete and sufficient explanation for the death
Intrinsic to child
Summary	Free text - include strengths and difficulties			√
Perinatal issues	Free text / 0-3			√
Acute physical illness	Free text / 0-3			√
Chronic physical illness	Free text / 0-3			√
Emotional / behavioural / mental health condition	Free text / 0-3			√
Developmental problem or disability	Free text / 0-3			√
Alcohol or substance misuse	Free text / 0-3			√
Child's Family and social environment				√
Summary	Free text - include strengths and difficulties			√
Poor parenting / supervision	Free text / 0-3			√
Child abuse / neglect	Free text / 0-3			√
Physical health of parent / carer	Free text / 0-3			√
Mental health of parent / carer	Free text / 0-3			√
Alcohol or substance misuse by parent / carer	Free text / 0-3			√
Domestic violence in home	Free text / 0-3			√
Family breakdown	Free text / 0-3			√
Family finances	Free text / 0-3			√
Child's wider/physical environment				√
Summary	Free text - include strengths and difficulties			√
Home safety	Free text / 0-3			√
Other physical environment safety issue	Free text / 0-3			√
Bullying	Free text / 0-3			√
Gang culture	Free text / 0-3			√
Wider social and policy environment	Free text / 0-3			√
Service provision/delivery				√
Summary	Free text - include strengths and difficulties			√
Recognition of sick child	Free text / 0-3			√
Team working/coordination of care and support	Free text / 0-3			√
Access to/availability of services	Free text / 0-3			√
Summary and actions				√
Case summary	Free text			√
Issues relating to the delivery of the review	Free text eg agencies not represented information not submitted to panel			√
Modifiable factors identified?	The panel has identified one or more factors which may have contributed to the death and which, by means of locally or nationally achievable interventions, could be modified to reduce the risk of future child deaths - Y/N			√
Modifiable factors identified - description	Free text			√
Learning points	Free text			√
Recommendations	Action			√
	Relevant agency			√
	Level (local/regional/national)			√
Refer death to another agency	Police			√
	Procurator fiscal			√
	Health and Safety Executive			√
	Serious Case Review panel			√
	Other?			√
Follow up plans for the family	Free text			√

Code list for ethnicity

Group A - White

1A - Scottish

1B - Other British

1C - Irish

1K - Gypsy/Traveller

1L - Polish

1Z - Other white ethnic group

Group B - Mixed or multiple ethnic groups

2A - Any mixed or multiple ethnic groups

Group C - Asian, Asian Scottish or Asian British

3F - Pakistani, Pakistani Scottish or Pakistani British

3G - Indian, Indian Scottish or Indian British

3H - Bangladeshi, Bangladeshi Scottish or Bangladeshi British

3J - Chinese, Chinese Scottish or Chinese British

3Z - Other Asian, Asian Scottish or Asian British

Group D - African

4D - African, African Scottish or African British

4Y - Other African

Group E - Caribbean or Black

5C - Caribbean, Caribbean Scottish or Caribbean British

5D - Black, Black Scottish or Black British

5Y - Other Caribbean or Black

Group F - Other ethnic group

6A - Arab, Arab Scottish or Arab British

6Z - Other ethnic group

Group G - Refused/Not provided by patient

98 - Refused/Not provided by patient

Group H - Not Known

List for place of event leading to death and place of death

Acute hospital Family home

Neonatal unit Foster home

A&E Other private residence

ICU/HDU Residential care setting

Psychiatric hospital/unit School/nursery

Paediatric ward Public place

Hospice

Outwith Scotland

Other

Not Known