Child Death Review

1. Child Death Review

2. Learning Objectives After working through this content the participant will be able to: • Explain the concept of child death reviews (CDRs) • Understand the purpose of the CDR process • Understand the critical importance of a multi-sector approach to the CDR process • Explain the elements and processes an effective CDR teams • Consider how CDRs might be implemented in countries with low levels of resources and interagency coordination

3. The development of this module • Effective child death reviews depend on a multi-disciplinary approach. • The development of this module has also adopted a team approach. • Thank you to Teri Covington, John Devaney, Shanaaz Matthews, Victor Palusci for their generous sharing of experience and materials.

4. The motivation for CDRs • Over the past 25 years, the world has made significant progress in saving young children’s lives. The rate of child mortality fell 62 per cent from 1990–2016, with under-five deaths dropping from 12.7 million to 5.6 million. (UNICEF) • The good news is that ending preventable new-born and child deaths is possible – within our lifetime. With a concerted, coordinated effort among policymakers, businesses, healthcare workers, communities and families, we can work together to provide affordable, quality healthcare for every mother and child. (UNICEF)

5. The under-reporting of fatal child abuse is a global concern • Multiple settings have shown the under-reporting of child abuse fatalities. • Only a 1/3 of these deaths are classified as homicide. • Fatal child abuse is poorly detected in routine data sources due to: • Difficulties identifying such deaths • Investigating and reporting of these deaths by police to Child protection services • A lack of standard definitions. • Deaths due to severe injury are most commonly detected but the omission of care usually remains undetected.

6. The motivation for CDRs • Globally, every 5 minutes a child dies as a result of violence (Global Partnership to End Violence Against Children). • Injury remains the leading cause of death and disability among children world wide (UNICEF). • In the U.S., injuries claim nearly 20,000 lives and permanently disable 30,000 children each year.

7. The motivation for CDRs is therefore to: • Understand the cause and factors associated with a child’s death • Examine how this cause and associated factors can be manipulated to prevent child deaths • Make recommendations regarding cause and associated factors • Pass the recommendations on to structures & agencies who have the mandate for implementing these recommendations • Advocate actively for implementation of the recommendations

8. The purpose/objectives of child death reviews are therefore to* • Ensure the accurate identification and uniform, consistent reporting of the cause and manner of every child death • Improve communication and linkages among local and state agencies • Enhance coordination of efforts • Improve agency responses in the investigation of child deaths * Covington et al., 2005, www.childdeathreview.org

9. The purpose/objectives of child death reviews are therefore to • Improve agency responses to protect siblings and other children in the homes of deceased children. • Improve criminal investigations and the prosecution of child homicides. • Improve delivery of services to children, families, providers and community members. • Identify specific barriers and system issues involved in the deaths of children.

10. The purpose/objectives of child death reviews are therefore to • Identify significant risk factors and trends in child deaths • Identify and advocate for needed changes in legislation, policy, and practices and expanded efforts in child health and safety to prevent child deaths • Increase public awareness and advocacy for the issues that affect the health and safety of children

11. Definitions of Child Death Review Panels and Processes • A Child Death Review Panel is A group of professionals who consider all child deaths in a given area to look for possible patterns and potential improvements in services to prevent future deaths. • A Child Death Review is A multidisciplinary community, telling a child’s story, one child at a time, to understand the causal pathway that leads to a child’s death, to identify how to interrupt the pathway for other children (Covington 2018).

12. Principles of Child Death Reviews (National Centre for Child Death Review) • The death of a child is a community responsibility. • A child’s death is a sentinel event that should urge communities to identify other children at risk for illness or injury. • A death review requires multidisciplinary participation from the community. • A review of case information should be comprehensive and broad.

13. Principles of Child Death Reviews (National Centre for Child Death Review)* • A review should lead to an understanding of risk factors. • A review should focus on prevention and should lead to effective recommendations and actions to prevent deaths and to keep children healthy, safe and protected. * Covington et al., 2005, www.childdeathreview.org

14. Outcomes should: • Improve investigations • Improve diagnosis of cause of death • Improves services to families • Improve agency systems • Prevents deaths

15. Potential Benefits • Cases may be better managed by the team. • Agencies learn to work together and more about the roles of other disciplines in relation to children. • Participants learn more about families and young children. • There is mutual quality control in respect of actions taken in relation to child deaths. • The multi-agency team provides a prevention forum.

16. Models of Child Death Review Teams • Are various • Should be designed to fit local circumstances and available resources • Some are government led; others by civil society organisations • The presence of civil society organisations and individuals may enhance accountability of public role-players

17. Core team members Palusci (2018) suggests that core team members include: • A medical examiner or coroner/pathologist • A law enforcement/police officer • A child protection service professional • A public health professional • A prosecutor • A paediatrician or other health care provider

18. Other team members may be drawn from (These may be invited on an “as needed” basis) • Emergency services (e.g., ambulance) personnel • Trauma or emergency departments at health facilities • Community mental health practitioner • School personnel • SIDS services providers • Domestic violence service providers

19. Other team members may include: • Tribal leaders • Religious leaders • The child’s family members, or someone who represents the family • If family members or a family representative are included, they are only present for the discussion of their “case”

20. In practice…. • In practice teams usually include a paediatrician, and/or medical doctor, representatives of the child protection service provider – usually a social worker, a pathologist, a coroner/prosecuting authority, police official, and any other professional considered necessary for the CDR process. • Team members may vary according to the need – for example where poisoning is suspected a toxicologist may be included.

21. Training of child death review team members • The core members of the child death review should be trained on the purpose, principles and processes of effective and productive review. • New learnings gained during the process of work should be noted and shared via reports and scientific papers.

22. The approach to reviewing child deaths • Teams must be multi-disciplinary and all team members respected for their contributions. • Broad teams tend to enhance the usefulness of the discussions • Team meetings should be confidential. This enables the development of trust and freedom of sharing and expression. • A reminder of the commitment to confidentiality should be signed at the beginning of each meeting as a reminder of this essential commitment and also to ensure that irregular or once-off attendees commit to confidentiality. • An example of a confidentiality pledge is available in Covington et al., A Program Manual for Child Death Review p. 135, available at www.childdeathreview.org

23. Leadership • One needs high-level leadership of child death review teams. • Leadership should make prevention the priority of child death reviews and not a fault finding process. • Leadership must listen to the input and recommendations of all members of the team. • Leadership must follow through on planned actions and recommendations that are not implemented.

24. Terms Used in Child Fatality Review • Sudden Unexpected Infant Death (SUID) • A general category of infants who die rapidly without warning by illness of different cause/manner • Sudden Infant Death Syndrome (SIDS) • A specific diagnosis, only after excluding other possible causes with complete investigation and autopsy. • Undetermined Cause and/or Manner • Cases that are not clear after investigation • Team review may help with clarity

25. Terms Used in Child Fatality Review • Cause of death = the medical explanation of the death • Injury, infection, cancer, toxin, heat or cold, malnutrition • Manner of death = Intent, including self versus others • E.g., acute gun shot wound: • Suicide - Intent to kill or injure self • Homicide - Intent to kill or injure another another • Accident or non-intentional - No intent • Undetermined manner - Unclear intent • Undetermined cause - Unclear why death occurred

26. When to review cases? This depends on your goals and opportunities for meeting • Active case review: as soon as possible or weekly • Helps investigation, case management, court action Maximizes team process and quality control • Serves siblings and other survivors Intervention with siblings should not wait • Trends can be summarized, which aids prevention • Retrospective case review: after months or end of year • Does not review the facts of each death • Summary of long trends, which may aid prevention • Less challenge to agency action

27. Setting the meeting agendas • Should be a team activity to ensure that all team members have the opportunity to give inputs specific to their discipline and/or perspective • The agenda for each meeting should be revisited at the beginning of each meeting, and followed flexibly. • It is essential that there is continuity from one meeting to the next to ensure that the follow up of past cases is not neglected.

28. Meeting minutes • Minutes of meetings should be taken, noting actions to be taken by team members, time lines for action and the team member responsible for the action. • Minutes of meetings and agendas for the following meeting should be distributed timeously to enable follow up of actions and preparation for the next meeting. • Each team member must commit to keeping records and minutes of meetings confidential and securely stored.

29. How to Review Cases • Each agency brings the case information for child new reviews or follow up on previous deaths. • Discuss one case at a time with all agencies sharing what they know. • Record basic case data for annual report on types of cases reviewed and basic outcome. • Agencies may collect further information if there are gaps that are relevant to the child death and surrounding circumstances and present this at the next meeting. • The gaps in information should be recorded and who has responsibility for filling the gaps and by when should be recorded.

30. Collecting information • Basic information may include: • Basic information: child’s age, gender, address • Hospital – medical illnesses – past and present • Coroner – Cause and manner of death • Law enforcement – possible suspect, past arrests • Prosecutor – court action, if any • Social services –records on siblings, or risk factors, any previous services to the family • Other agencies may provide useful information as required.

31. How to Review Cases After each agency presents their information: • Allow for brief questions to clarify the interpretation of certain facts • Summarise the salient inputs • List questions/issues that are not answered and assess what might resolve that issue. • Each agency is responsible to participate but retains their separate authority over their work.

32. How to Review Cases - After each new case review: Create a “to-do” list for team members to follow-up and report on during the next meeting - Old cases: follow-up and new action items Follow up on assignments or new information Update the to-do list if further action is required The peer group can keep the team accountable

33. Analyze data, write reports, and support prevention programs • Write periodic and/or annual reports and share with the public and other role-players working in the children’s sector. • Reports can be used to motivate for, initiate and/or support local prevention programs for identified problems – examples include: • Accidental Injury Prevention • Drowning prevention, bicycle safety, traffic safety, fire safety

34. Death Review and Response Cycle and Process

35. Remembering a child’s preciousness • This is critical – each death represents the life of a child • In one US state a photograph of the child is put on the table during discussion of the case. • This emphasises the right of every child to recognition and justice and the individuality of each child.

36. Child Death Reviews – caring for the child’s family • Child Death Reviews should keep an appropriate balance between forensic, psycho-social and medical requirements and supporting the family at a difficult time. • When a child dies, in any circumstances, it is important for parents, siblings, and extended families to understand what has happened and whether there are any lessons to be learned. • In the immediate aftermath of a child’s death, parents, and carers should be offered support them throughout the child death review process. In addition to supporting families and carers, staff involved in the care of the child should also be considered and offered appropriate support.

37. Helping the Surviving Family • Referrals to other sources of support and bereavement counselling may be necessary. • Families may need help in linking with resources because of post-bereavement depression, anticipation of blame for the death, etc. • A resource list for this purpose should be compiled. • remain aware of the needs of siblings who may require services.

38. Example of pamphlet for family members • http://media.education.gov.uk/assets/files/pdf/t/the%20child%20death%20review%20a%20guide%20for%20parents%20and%20carers.pdf • This explains: • The purpose of the pamphlet • The purpose of a child death review • The makeup of a child death review panel • The process of the review • The feedback process

39. Caring for the members of the child death review team • Reviewing child deaths may at times result in difficult emotional responses in team members • Frustration and anger with service providers and carers may arise when services and/or parenting capacity fails the child • This can impact on objective thinking about solutions and recommendations for the prevention of child deaths • It is therefore essential to provide support to team members and opportunities for feelings to be expressed in a confidential and accepting context

40. Activities for team support and building • Contact other teams in your region and share each other’s learnings • Teams can support themselves and each other • Education: give presentations on specific topics in your field to the other members of your team • For example, knowledge in child development and family interaction is important for all team members but not all team members may have this content in their professional training.

41. Child Death Review in Developing and Low-Middle Income Countries • CDR’s may be difficult to initiate due to the shortage of professional resources and time constraints on those professionals that do work in the field of children’s services as most will have much higher caseloads than their colleagues in less resource countries. • Government and other service providers may perceive other issues as being of greater priority

42. Child Death Review in Developing and Low-Middle Income Countries • Difficulties in accessing information about the circumstances around the death may be challenging due to limited literacy of adult populations and even service providers. • A lack of resources may limit the implementation of recommendations arising from the CDR process. • A CDR project may thus have to start small as in a limited pilot project that over time will demonstrate the preventive value of this process. • Participants may require active and consistent motivation to become and remain involved.

43. Child Death Review in Developing and Low-Middle Income Countries • “Child death auditing (reviews) can be done in resource-limited settings and yield useful information of gaps which are linked to preventable deaths; however, using the data to produce meaningful changes in practice is the greatest challenge. Audit is an iterative and evolving process that needs a structure, tools, evaluation, and needs to be embedded in the culture of a hospital as part of overall quality improvement, and requires a quality improvement team to follow-up and implement action plans.” (Sandakabatu et al., 2018)

44. Child Death Review in Developing and Low-Middle Income Countries • However successful examples of child death review projects do exist in developing and LMI Countries. • See: https://adc.bmj.com/content/archdischild/103/7/685.full.pdf (Child Death Reviews in the Solomon Islands). file:///C:/Users/Joan%20van%20Niekerk/Downloads/11382-55687-1-PB%20(1).pdf (Child Death Review in South Africa)

45. Examples of available resources www.childdeathreview.org/ This website contains many resources such as • A “How to” manual • A Data Collection Model • Contact details for U.S. state child death review teams

46. Examples of available resources: Child Death Review: Statutory Guidance (UK) • Available at: • https://consult.education.gov.uk/child-protection-safeguarding-and-family-law/working-together-to-safeguard-children-revisions-t/supporting_documents/Child_death_review_stat_guidance.pdf

47. Child Death Review: Statutory Guidance (UK) This document covers (inter alia): • Immediate notifications and decision making • Investigating and information gathering • The child death review meeting • The child death panel meeting • Family bereavement and support. • The roles of specific agencies.

48. Other References • http://www.childdeathreview.org • http://www.childdeathreview.org/finalversionprotocolmanual.pd • http://cmx.sagepub.com/content/15/2/195.extract • http://www.scotland.gov.uk/Publications/2005/07/1485820/58425 • http://c.ymcdn.com/sites/www.ispcan.org/resource/resmgr/link/link.13.1.english.pdf • http://phpa.dhmh.maryland.gov/mch/Documents/Newsletter%20FALL%202012%20Final.pdf • https://www.gov.uk/government/publications/child-death-reviews-completed-in-england-year-ending-31-march-2012 • http://www.aifs.gov.au/cfca/pubs/factsheets/a142119/index.html