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Learning from Child Deaths in Wales Dr Aideen Naughton Designated Doctor Child Protection

Learning from Child Deaths in Wales Dr Aideen Naughton Designated Doctor Child Protection. Why review child deaths?.

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Learning from Child Deaths in Wales Dr Aideen Naughton Designated Doctor Child Protection

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  1. Learning from Child Deaths in WalesDr Aideen NaughtonDesignated Doctor Child Protection

  2. Why review child deaths? • Article 6 UNCRC requires States Parties to recognise the inherent right to life of every child and ensure to the maximum extent possible the survival and development of the child. • Article 2 ECHR states that; Everyone’s right to life shall be protected by law.

  3. Why review childhood deaths? Source: Sidebotham & Fleming (2007)

  4. How are deaths reviewed in Wales? • Coroners Inquests • Serious Case Reviews • Hospital child mortality meetings • Sudden unexpected death in infancy and childhood (SUDI Protocol) • CEMACH (confidential enquiry into maternal and child health) CDR Pilot

  5. Death of an infant or child Expected Unexpected Standard bereavement care Suspicious? Interagency Rapid Response/SUDI Child Protection / Criminal Investigation Death registration Information gathering Coroner’s Inquest Final Case Discussion Serious Case Review Child Death Overview Panel

  6. Welsh CDR Pilot • All child deaths entered on a single database Autumn 2009 onwards • Themed reviews of particular types of death • Deaths by apparent suicide • SUDI with ‘overlaying’

  7. Why Children Die? CEMACH report of a pilot study2006 • 26% of cases contained avoidable factors most frequently an identifiable failure by any agency (including parents) with direct responsibility towards the child. • 43% of cases contained potentially avoidable factors

  8. Reviewing Child DeathsWhat should be the focus? Potentially avoidable Deaths Deaths from abuse or neglect Other homicides Accidents Traffic, home, playground etc. Suicides Deaths from natural causes not normally fatal Parental care; medical responses; other factors

  9. Serious Case Reviews • When a child dies, and abuse or neglect are known or suspected to be a factor in the death. • Where a child sustains a potential life threatening injury, or serious and permanent impairment of health and development, or has been subjected to serious sexual abuse and the case gives rise to concerns about inter-agency working.

  10. Purpose of SCR s • Establish whether lessons can be learned locally. • Identify clearly what those lessons are, how they are to be implemented and what is expected to change as a result. • To improve inter-agency working

  11. Victoria Climbie died aged 8 years, 2000 She was hypothermic, malnourished and had 128 separate injuries on her body indicating she had been beaten with a range of sharp and blunt instruments. No part of her body had been spared. Marks also indicated that her arms and legs had been tied.

  12. Peter Connelly died aged 2 years, 2007 Post mortem • More than 50 injuries, many to face which made him virtually unrecognisable. • 15 wounds to his mouth • A tooth that must have been swallowed after a violent blow to the face. • Torn ear • 8 fractured ribs • 2 missing fingernails, a missing toenail and missing part of a finger • Fracture dislocation of the thoraco-lumbar spine

  13. Where are the lessons? Can we learn from the families involved ? Can we learn from the behaviours of the professionals ? Can we learn from the systems and structures within organisations ?

  14. CR 8 months 40 fractures AB 3 weeks SID,Fractures AC 4 weeks Skull fracture NW 8 weeks Overlying TW 3 weeks Skull fracture GA 8 weeks Skull, rib fractures BW 8 months Skull, rib fractures LL 2 years Skull, multiple fractures AC 2 months SDH,RHs,Bruising

  15. Parental Characteristics (%)

  16. Findings from professional practice • Overall patterns • Over optimism • Factors affecting parenting capacity • Family receptiveness to services • Hostility and aggressiveness • Complaints • Disguised compliance • Closure

  17. Professional Practice cont’d. • Inadequate sharing of information • Poor assessment processes • Ineffective decision making • A lack of inter-agency working • Poor recording of information • Lack of information on significant males But why ?

  18. “ no single professional appreciated the whole picture because they either lacked information, or failed to seek information from wider sources, or had a narrowly defined perception of their involvement in the case” (Reder and Duncan, 2003)

  19. Different clustering of professionals involved. Brandon sample 20 SCR 10 were under 1years ( health) 8 were school age (education) 12 had involvement with hospital staff (health) 13 had special needs (health and education and disability services)

  20. Children untapped sources of expert knowledge. “ Little attention had been paid to what the children said or how they presented over many years of professional involvement” Brandon et al 2005

  21. Have we changed ? • Have we read the procedures ? • Do they help to save children ? • Are we able to think the unthinkable ? • Are we any better at reporting and sharing the right information ?

  22. What are our attitudes to childhood? • How do we perceive parents/carers who abuse ? • Have we got the balance right between protection and prosecution? • What about expertise- who do we trust?

  23. Do we ask the right questions? • Are we prepared to stand our ground if we believe a child is at risk ? • Do we consider what children really want ? • Do we work in environments that support us?

  24. ‘Although it is impossible to ‘prove’, it is our view that several children in the assessment sample are alive today who otherwise would not be if alert and skilled social services, police and health professionals had not intervened in diligent ways’ Dale, Green and Fellows, 2002

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