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Learning from children’s deaths: Systems approaches to analysis

This article discusses the systematic review of children's deaths, focusing on preventing future child deaths. It covers data collection, analysis, identifying preventive actions, and implementing recommendations. The article emphasizes a systems approach to analysis and highlights key questions and factors that influence practice. It also explores the process of developing recommendations and action plans to prevent child deaths.

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Learning from children’s deaths: Systems approaches to analysis

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  1. Learning from children’s deaths: Systems approaches to analysis

  2. What’s it all about? • The process of systematically reviewing all children’s deaths is grounded in respect for the rights of children and their families, and geared towards preventing future child deaths.

  3. How can we make child death review more effective? • Data collection and collation • Gathering and using relevant data • Analysing the data • Systems approaches • Identifying effective preventive actions • Disseminating lessons • Implementing and monitoring recommendations • Building and maintaining effective structures

  4. Child death review process

  5. Analysis Cause of death and case summary Four domains, factors graded 0 - III The child Family and environment Parenting capacity Service provision Categorisation of death; specific contributors Preventability Issues; learning; recommendations; action

  6. Key questions • What is the nature of the condition? • Incidence and prevalence • Aetiology • Contributory factors • Mortality • Management and outcomes • Is this death the tip of an iceberg? • Is there any effective intervention?

  7. Key questions • What factors have we identified in any of the domains? • To what extent are these isolated factors or indicative of wider systemic issues? • What factors have we identified that may be amenable to intervention?

  8. Systems methodology • Recognises complexity • Seeks to understand the underlying reasons that led individuals to act as they did • Seeks to avoid hindsight bias • Considers the viewpoint of the individuals at the time • Transparent, structured approach to collecting and analysing data • Uses research and case evidence to inform the findings

  9. A systems approach to analysis Adverse Outcome

  10. A systems approach

  11. Factors that influence practice (based on Vincent et al, 1998) Corporate Culture • Institutional context • Economic and regulatory context • Organisational and management factors • Financial resources and constraints • Organisational structure • Safety culture Local environment • Work environment • Staffing levels and workload • Equipment • Team factors • Communication • Supervision and support • Team structures • Task factors • Clarity of task • Availability and use of protocols

  12. Factors that influence practice (based on Vincent et al, 1998) • Individual (staff) factors • Knowledge and skills • Motivation • Physical and mental health • Patient/client characteristics • Complexity and seriousness of condition • Language and communication • Personality and social factors

  13. A worked example • 17 year old boy with cerebral palsy • Admitted to DGH for gastrostomy • Discharged after 2 hours • Developed vomiting and lethargy • Reviewed by CCN • Found dead after 24 hours • Autopsy revealed perforation secondary to paralytic ileus • What were the key incidents or active failures that may have contributed to his death?

  14. A worked example • Patient/parent factors • Individual staff factors • Surgeon • CCN • Paediatrician • GP • Task factors • Team factors • Work environment • Organisational and management factors • Institutional context

  15. Child death review process

  16. Taking action to prevent child deaths • Education: • Strengthening Individual Knowledge and Skills (Practitioners) • Empowerment: • Informing the public (community education) • Mobilizing communities • Enforcement: • Influencing policy and legislation • Advocacy and health promotion • Engineering: • Modifying the physical environment • Changing organisational structures and practice

  17. Developing recommendations and action plans

  18. Information (Data) Stories Understanding Motivation Learning Lessons Disseminating Learning Achieving effective outcomes Developing appropriate recommendations and action plans Implementation

  19. Summary • Child death review stems from respect for the child and family • Many child deaths are potentially avoidable • Joint agency working is essential • Child death review should lead to positive action to safeguard and promote the welfare of children • This requires • effective and appropriate information gathering and analysis; • formulation, implementation and monitoring of relevant (evidence-informed) actions; • dissemination of learning • appropriate structures

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