Child Death Reviews: Scottish Government Steering Group Report

Chapter 1 Introduction and Model

1.1 Although the number of child deaths in Scotland has decreased in recent years, Scotland has a higher mortality rate in children and young people compared to many other Western European countries. In Scotland each year, there are approximately between 350 and 450 deaths of people aged under 18 years, with most occurring in children aged under 12 months of age, and those aged 16 years and over.

	2007	2008	2009	2010	2011	2012	2013	2014	2007-11 average	2008-12 average	2009-13 average	2010-14 average
Under 1	272	253	235	218	238	217	186	207	243	232	219	213
Age 1-14	120	103	98	90	90	93	83	81	100	95	91	87
Age 1-18	251	226	208	193	160	153	155	134	208	188	174	159
Under 18 (0-17)	462	433	410	371	369	348	322	328	409	386	364	348
Age 15-18 (inc)	131	123	110	103	70	60	72	53	107	93	83	72

Extracted from http://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/deaths/deaths-time-series-data

1.2 Currently in Scotland there are reviews of deaths carried out in certain circumstances, in different fora, using different data collection processes. There is no consistent process for reviewing a child's death. There is no uniform approach. There are a number of different formal and informal mechanisms that exist but there is considerable geographical variation across Scotland, and mechanisms are often designed only for certain categories of childhood deaths. Uniform data collection and the sharing of any lessons, at local and/or national level are inconsistent, or not present. Examples of reviews include a Sudden and Unexpected Death in Infancy (SUDI) review; a Significant Case Review by Child Protection Committees; Adverse Event Review or a Fatal Accident Inquiry (FAI); there can be criminal or civil proceedings; hospital mortality and morbidity reviews; neonatal reviews; there exist a number of different fora using different information, operated by different agencies, with legitimate and different purposes. An overview would suggest some lack of uniformity in approach though clearly different fora do have different purposes. There would be considerable wisdom - where at all possible - for data collection to become more standardised. For example upon the death of a child, information, collected in one uniform method, could clearly assist different fora. This is not to limit the purposes and duties of the different agencies but is to assist in uniform recording, uniform standards, and the avoidance of duplication.

1.3 The Scottish Government set up a Child Death Review Working Group to explore the current practice of reviewing child deaths in Scotland and to consider whether Scotland should introduce a national, collaborative, multi-agency system. Scottish Ministers accepted the recommendation in the Working Group's report^[2]

"that Scotland should introduce a national Child Death Review System and that a Steering Group be established to develop the process and to identify costs and funding, taking into account a pilot which is currently underway [Ruby Reviews, University of Dundee] which will inform the way the system is set up and the most cost effective way of delivering the components."

1.4 A Child Death Reviews Steering Group was established, chaired by David Jack, Advocate. It comprised representatives from:

• Care Inspectorate
• Child Health Commissioners
• College of Emergency Medicine
• Convention of Scottish Local Authorities (COSLA)
• Crown Office and Procurator Fiscal Service
• Faculty of Public Health
• Healthcare Improvement Scotland
• Information Services Division, National Services Scotland, NHS Scotland
• Paediatric Pathology
• Police Scotland - also representing Family Liaison Officers
• Royal College of Emergency Medicine, Scotland
• Royal College of Paediatrics and Child Health (RCPCH)
• Royal College of Psychiatrists in Scotland
• Scottish Ambulance Service
• Scottish Government Child and Maternal Health
• Scottish Government Child Protection
• Scottish Government Senior Medical Officer
• Scottish Neonatal Consultants Group
• Social Work Scotland
• Third Sector
• University of Dundee Fatality Investigation and Review Studies (pilot of child death reviews). (see Annex 1)

1.5 The remit of the Steering Group was to establish a national framework for reviewing child deaths in Scotland and to determine the age range and deaths to include and exclude. The Group agreed all deaths of children and young people up to the date of their 18^th birthday and care leavers in receipt of aftercare or continuing care, who die up to the date of their 26^th birthday, should be reviewed. The function of the framework proposed is to review the circumstances surrounding the death in a nationally uniform manner, and in a collaborative, inquisitorial, multi-agency, and "no blame" approach. The framework should operate within the context of the number of existing review arrangements and should not duplicate this work. It is not part of the remit of this Steering Group to re-organise existing structures. In any event, the purpose of a Child Death Review is different. The desired outcomes of the framework are to:

• Improve communication with families;
• Gather accurate information and implement consistent reporting of the cause and manner of each death;
• Identify significant risk factors and trends to be disseminated locally and/or nationally; and inform Scottish Government policy in order to reduce the number of child deaths;
• Identify and alert implications for others and/or for future births; and
• Improve inter-agency responses in the investigation and structured review of child deaths.

1.6 A very significant number of the deaths are in the 0-1 year age bracket. Such deaths can often be related to prematurity and congenital abnormalities. Establishing the cause and manner of death for these children can be relatively straightforward. For older children with life limiting conditions and complex needs, and for young people who die through self-harm, drug and alcohol-related deaths and accidental deaths, the factors that may have contributed to the death are far broader and very varied. There is a need:

• for every death to be subject to a Child Death Review Panel review as existing structures do not necessarily cover all deaths.
• for multi-agency child death reviews.
• for an initial process at local level to consider all deaths to inform Child Death Review Panels.
• for different input to child death reviews of neonatal, and other, deaths.
• for a Child Death Review Panel to have flexibility to seek information and expertise as appropriate in the circumstances.
• to identify modifiable or preventable factors from deaths.
• for local and national collation of modifiable factors, trends, causes and circumstances to inform education and learning.

None of the above affects existing structures, nor is it duplication.

1.7 The Steering Group met on 5 occasions between January and June 2015. A briefing paper was circulated wider than the Group members following the first 4 meetings. Comments were received, collated and considered. Annex 2 provides a list of the agencies involved in this process.

1.8 The Children and Young People (Scotland) Act 2014, furthers the Scottish Government's ambition for Scotland to be the best place in the world to grow up by putting children and young people at the heart of planning and services, and ensuring their rights are respected across the public sector. The duties of the Act upon Ministers and others, promote that ambition. There is clear purpose to improve services and to support children. It puts in statute access to a Named Person and for a single, coordinated, planning process to be put in place.

1.9 The Getting it right for every child^[3] approach seeks to ensure focus on the child and a uniformity of process and approach. This includes working across organisational boundaries and maintaining child focus. There is a desire for a consistency in data collection.

1.10 No child death should miss being reviewed.

Purpose of a Child Death Review

1.11 The purpose of a Child Death Review will be to:

• evaluate information about a child's death;
• consider the child's wellbeing concerns; relevant family and environmental aspects; relevant parenting aspects; service provision and delivery;
• engage with relevant family as appropriate;
• categorise the likely cause of death;
• consider any modifiable factors in relation to the death;
• identify lessons to be learnt from a child's death;
• inform local and national learning of child death issues.

National Child Death Review model for Scotland

1.12 The recommendation is that there should be one Child Death Reviews National Resource Centre (NRC) - ideally hosted within existing public sector (NHS) infrastructure, though preserving its independence and independent scrutiny. This would be the headquarters of the Scottish national system. It ought to initially have staff of one full time coordinator, one full time data analyst and one full time administrator. Additionally there should be 3 Regional Child Death Reviews Offices situated in the North, West and East areas of Scotland. Such a broad geographical layout is already used by other national agencies, such as Police Scotland, the Procurator Fiscal Service and the Scottish Ambulance Service. The geographical layout would also meet with a very broad division of likely workload. Each Regional Office ought to initially have staff of one full time coordinator and one full time administrator.

Role of the National Resource Centre.

1.13 The NRC should be informed through National Records of Scotland/NHS Central Register/Local Authorities/the Care Inspectorate of the deaths subject for review. The NRC, which may have a management committee if so required, should have the role of central governance of the national child death review system. The NRC should also have a role in instigating the review by informing the appropriate regional office closest to the residence of the deceased child or young person who will then commence the process. The NRC should have overall strategic accountability for regional offices including: assuring a uniformity of process; assuring the effectiveness of learning opportunities; assuring that reviews occur; budgeting; finance; undertaking national policies and issues; quality assurance; receiving final reports of completed reviews; and collating and reporting learning to facilitate national changes in policy and practice where required. The NRC should have the ability to audit and adapt procedures to promote the development of the national CDR system.

Role of the Regional Office

1.14 The role of the Regional Office will principally be to provide the operational and delivery processes which support the monthly Child Death Review Panels. The Regional Office staff will recruit and identify Panel members, including the Chairs. They will request the information from agencies prior to the Panel meetings to provide secretariat for the Panel, liaise with the Chair, serve the Panel, record the decisions of the Panel, seek to initiate local learning, advance national learning and feedback to the NRC, against a number of process outcomes.

Interface with other review processes

1.15 There are existing review mechanisms such as, though not exhaustively: hospital mortality and morbidity reviews; neonatal reviews; FAIs; SUDI reviews; Significant Case Reviews; Court Processes; Child Protection Committee Reviews, and Adverse Events Reviews. Each has its own purpose. A Child Death Review will not replace these mechanisms. A Child Death Review may use the results and information from these sources if reasonably available in the conduct of its purpose. A Child Death Review may request information from any pertinent source. It may adjourn consideration of a case, as it sees fit. It may seek specific expertise to assist its function, as it sees fit. It may use and rely upon the findings of previous considerations of the death.

Information gathering

1.16 The Child Death Review process will gather information from relevant sources regarding the death, in a consistent manner throughout Scotland. An example of potential forms for the gathering of information is at Annex 3. Supplementary forms for specific types of death may be developed if required.

1.17 The recommendation from the Steering Group is that there is one specific form used for the initial notification of the death to the NRC and from the NRC to the Regional Office (Form 1). There should be one form used for gathering appropriate information from relevant external sources (Form 2) and there should be one form used for the review conclusion (Form 3).

• These forms should be used consistently.
• These forms may be amended by the NRC in collaboration with relevant parties.
• As stated at paragraph 1.2 there would be considerable wisdom in a uniformity of approach, or an amalgamated approach, to information gathering across the different agencies involved in the consideration of child deaths.
• CDRPs should be able to seek information from, for example, Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE) or other agencies as they see fit.