Child Death Review Report : Scottish Government Child Death Review Working Group
A report by a Scottish Government short-life working group which explored current practice in Scotland and considered whether Scotland should introduce a national collaborative multi-agency system for reviewing the circumstances surrounding the death of a child.
Appendix 4: Child Health Commissioner responses
In May 2013, the Child Health Commissioners within each territorial Health Board in Scotland were sent a questionnaire survey with regards to child death review processes in their area. 12 out of the 14 territorial NHS Boards participated in this Child Death Review Audit. The questions are below with a summary of the responses.
OPERATIONAL ASPECTS |
Does your Health Board area have a child death review group? |
3 Boards do have a child death review group 8 Boards do not 1 Board was unsure. Comments from Boards who said no or were unsure:
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If yes can you describe its role, remit and membership? |
1 Board reported annual multi-disciplinary childhood mortality meeting to review all post-neonatal deaths in infancy and childhood 3 Boards reported meetings took place to learn lessons 1 Board reported the remit was to review any unexpected child death in relation to child protection. 1 Board reported role is to ensure governance of child protection. 2 Boards reported Significant Incident procedure would be followed. 1 Board reported PRAMS monthly meetings - cases are selected and presented for discussion. Chair of PRAMS also leads the local risk group and links PRAMS' identified issues into the risk agenda. 1 Board reported its perinatal mortality group is a multi-disciplinary child death review group. Membership varied - medical staff, paediatricians; head of paediatric services; paediatric nursing, A&E, anaesthetic staff; regional PICU colleagues, child protection, pathologist, clinical directors, consultant relevant to specialty, clinical risk manager, critical incident response group involvement, other members identified relevant to individual cases |
Do you have a Paediatric review and audit of mortality (PRAM) in place? |
8 Boards have a PRAM in place 4 Boards do not |
Within the Paediatric setting, do any other reviews occur following a child death? |
Boards reported other reviews occur when appropriate:
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If yes can you describe these in terms of their roles, remits and membership? |
Role and remit as per:
Membership includes staff concerned, SUDI paediatrician, GP, pathologist, paediatric and obstetric consultants, associated nursing and midwifery staff, obstetricians, neonatal nurses, multi-disciplinary, consultant who leads on quality and safety, emergency medicine, anaesthetics, PICU, primary care staff, social workers, education, police, procurator fiscal, public health |
Out with the Paediatric setting are you aware of any specific reviews occurring following a child death, for example in Psychiatry following a child suicide? |
6 Boards reported specific reviews occurred, eg Significant Clinical Incident Review Group, Significant Case Reviews for child protection, Initial Case Review or Serious Case Review for child on child protection register/LAC or known child protection concerns, reviews led by specialist children's services, reviews led by the Ambulance Service, CAMHS Mental Health Critical Incident/Pathway following Suicide/Unexplained Death reporting processes. 4 Boards reported no specific reviews occurred 1 Board reported no child suicides |
If yes can you describe these in terms of their role, remit and membership? |
Adverse significant event policy, significant case review if potential child protection issue, Mental Health Critical Incident Review, family and community support, bereavement counselling, Critical Incident Review, Suicide Review Policy Role and remit as per Scottish Government guidance for Child Protection. Membership includes lead clinician determined by the circumstances, CAMHS, psychology, educational psychology, Associate Medical Director, Clinical Director, General Manager |
Are child deaths which are "expected" (for example following a long illness) routinely reviewed in your Health Board? |
4 Boards reported "expected" child deaths are routinely reviewed 6 Boards reported they are not 1 Board was unsure and 1 Board was unsure for acute services. |
If yes can you describe these reviews in terms of their role, remit and membership if not already covered above? |
Annual mortality meeting, as per Child Death Review process, PRAMS, Significant Event Analysis meetings, exploring need to set up Child Death Review Group. |
Are there any multi-agency groups (involving Health, Social Work, the Police and/or others) which review child deaths? |
9 Boards reported yes 2 Boards reported no |
If yes can you describe these in terms of their role, remit and membership if not already covered above? |
Child protection committee review sub-group, significant/serious case reviews, child protection committees, formal meetings to discuss child protection deaths and SUDI. Membership can be multi-discplinary including health, social work, police, lead paediatricians for child protection |
Does your Health Board area have any other processes in place to review child deaths not covered here? |
3 Boards reported yes 8 Boards reported no |
If yes, can you describe these in terms of their role, remit and membership? |
Potentially as part of HSMR (Hospital Standardised Mortality Ratios) patient safety programme, other mechanisms such as significant untoward incident investigation, discussed at Clinical Governance and Risk Management Group, SUDI Membership of the groups includes lead paediatrician, pharmacist, dental, GP, Scottish Patient Safety Programme representative, Out-of-Hours, paramedics, social work, A&E, primary/secondary care, pathologist, SUDI paediatrician/review officer |
STRATEGIC ASPECTS |
Are the lessons identified from any of the reviews listed above disseminated and acted upon by the relevant agency involved? |
10 Boards reported yes adding:
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Are you aware of lessons being shared with other areas/agencies after any of the reviews listed above? |
7 Boards reported yes 1 Board reported no 1 Board was unsure 2 Boards reported yes but not for all reviews Lessons were shared with Child Protection Committees and CPC Review subgroup, Clinical Management Teams, Multidisciplinary Teams |
If yes, which reviews does this occur for, how are lessons shared and who are they shared with? |
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Do you feel lessons learned from child deaths are effectively disseminated to other areas and agencies (for example changes are made in response to learning points identified)? |
6 Boards said yes 1 Board said no 2 Boards were unsure One Board reported Yes for specialist children's services, currently being audited for child protection and no, could improve, for acute services. |
If yes, can you describe for which reviews this occurs and give examples as to what enables the process to be effective?
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If lessons are not shared/ not effectively shared, do you feel that there is a need for a process to ensure that this does occur? |
9 Boards responded yes with comments:
1 Board was unsure |
Finally, do you have any comments not covered by the questions above? In particular do you have any comment on the proposal to consider setting up a Child Death Review process in Scotland? |
Comments included:
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Contact
Email: Mary Sloan
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