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

Appendix 5: Effectiveness and structure of Child Death Review Process: literature review

1. This section details the results of a non-systematic scoping review of the literature carried out in April 2013 and designed to rapidly appraise the available evidence as to the effectiveness and most appropriate structure of a child death review process.

2. In April 2008, new procedures for reviewing child deaths were instituted across England and each local authority was required to establish a child death overview panel to review all deaths of children from birth to 18 years. There are also well-documented processes in countries such as the United States^{13,18,20,33,38} and New Zealand.

3. There is no widely accepted definition or approach taken towards carrying out a child death review. However, the process tends to involve a multiagency review of child deaths with the aim of better understanding how and why a child dies, and the findings being used to take action to prevent other deaths.

4. Evidence suggests that having a robust child death review process can be an effective way of identifying and addressing preventable factors.^31,32,33,34. One paper drew together numerous examples of the benefits of a child death review process demonstrating it can positively influence policy and legislation, change organisational structures and practice, mobilise communities, strengthen individual knowledge and skills, educate communities and influence individual case management³¹.

5. A comprehensive overview of the approaches taken in reviewing child deaths was carried out by the Dartington Social Research Unit on behalf of the Scottish Executive in 2005.³⁵ The report summarises the features of a good system, and these include having political and senior professional backing, having clarity over what the review is seeking to do and clarity over how it fits in with other agencies and investigations (for example police investigations). Additionally it stated that the recommendations made following a review should be realistic, useful and disseminated widely.

6. A report by the Confidential Enquiry into Maternal and Child Health (CEMACH) highlighted some areas of importance in relation to the new child death review responsibilities arising in England as a result of Chapter 7 of "Working Together to Safeguard Children" in 2008. Chapter 7 details that there should be in depth review of all unexpected child deaths. CEMACH had previously found that there were avoidable factors in around half of deaths falling outside those which would be classified as being "unexpected" and therefore recommend that as many child deaths as possible should be reviewed in as much depth as possible¹⁷.

7. Additionally, CEMACH had found that multidisciplinary panels with full access to case notes were essential for the identification of avoidable factors. The independence of the panel was highlighted as a key factor in enabling it to carry out its duties effectively³⁶.

8. The CEMACH statement about multi-disciplinary panels was also made in a mixed methods study of early Child Death Review panels in England³⁷. It also reflects the recommendations of the National Maternal and Child Health Center for Child Death Review in the US³⁸. The importance of a degree of independence of the process was highlighted in another paper, which stated that whilst having panel members with local experience is useful, independence can be achieved through having for example an independent chair³².

9. One US study quoted a number of anecdotal pieces of evidence of the impact of effectively disseminating the recommendations following a child death review, for example a child death review team worked with industry to place warning labels on large buckets following a series of child drownings. However, it also found that child death review teams were better at assessing problems than proposing effective recommendations³³.

10. Limitations highlighted in a non-systematic review paper examining the US system included child death review teams having insufficient resource to carry out their role and the lack of formal criteria by which the reviews may be evaluated. The paper also discusses the importance of defining whether a child death review is carried out as part of the investigative process into a child's death or as a separate retrospective review not feeding in to the investigation. The benefits or drawbacks of either approach are not discussed³³.