Dr Peter Sidebotham of outlines the new procedures introduced in April 2008 (1) for responding to and reviewing child deaths.

There are two main processes involved which have the potential to improve services for bereaved families and ultimately to help reduce the numbers of child and infant deaths. The initial process is the “Rapid Response” to each unexpected child death
This builds on the joint agency approach already being used in many parts of the country and described in the Kennedy Report (2). This involves examination at the A&E department, a home visit and a post mortem examination drawing on information already provided. The aim is to answer not just “what did this baby die of?” but the broader question of “why did this baby die?”

The second process is that provided by Child Death Overview Panels. These are set up in each Local Authority to learn lessons for prevention of future child deaths. The panels, which consist of professionals and lay representatives from a range of backgrounds, typically meet every one to three months and will review information provided by health, police and child welfare practitioners about the child, the family and environment, and any service provision or need. The panels use a structured framework to review the deaths and to establish whether there are any lessons to be learnt from individual deaths or from any patterns of deaths in their area. The panels will be able to make recommendations which would go to the Local Safeguarding Children Board, to the Director of Public Health and to other bodies working with children and families.

The emphasis of these panels is to look at lessons to be learnt rather than undertaking a detailed investigation into any individual death. It has been my experience that often parents and other family members have very pertinent questions or suggestions that can go to the panel and may help to promote better services for children and families.

The development of these Child Death Overview Panels has been supported by two recent national studies. The Confidential Enquiry of Maternal and Child Health (CEMACH) recently completed a study looking at a total of 126 child deaths reviewed by five regional panels (3). At the same time a smaller study, completed on behalf of the Department for Children, Schools and Families (DCSF) worked with 9 “early starter” child death overview panels to explore their experience in establishing and running their local panels (4). Both studies demonstrated the potential for child death reviews to work and to be effective. It was challenging to note that in the CEMACH study, avoidable factors were identified in 26% of the deaths reviewed with potentially avoidable factors in a further 43%. This means that, although overall death rates have fallen over the years, there is still scope for more children’s lives to be saved.

The government commissioned a team from the University of Warwick to produce training materials to support local professionals in responding to and reviewing child deaths. The training materials include lectures, case studies and a series of information sheets and proformas for professionals to use.

References:
(1) HM Government (2006). Working Together to Safeguard Children. Department for Education and Skills. London, DfES. 2006.
(2) RCPath and RCPCH (2004). Sudden unexpected death in infancy: A multi-agency protocol for care and investigation. London, Royal College of Pathologists, Royal College of Paediatrics and Child Health.
(3) Pearson, G. (2008). Why Children Die: A Pilot Study 2006; England (North East, South West and West Midlands), Wales and Northern Ireland. London, CEMACH.
(4) Sidebotham, P., J. Fox, et al. (2008). Preventing Childhood Deaths: An Observational Study of Child Death Overview Panels in England. London, Department for Children, Schools and Families.