Child Death Review Pilot

1. Child Death Review Pilot 6 October 2010 Child Death Review Pilot Presenter: Beverley Heatman

2. Background • An analysis of child deaths is at the heart of any study of child health • Interesting as national mortality figures are, they do not give enough detail to focus on prevention both at a local and national level • There is a need to investigate deaths in more detail, focussing on prevention, hence Child Death Reviews (CDRs). Child Death Review Pilot

3. Child Death Reviews • Were first established in California in 1978 as a result of concern on the part of parents and professionals over the increasing number of preventable deaths • Now all States in the USA apart from Idaho have a CDR process in place • Also in Australia, New Zealand and Canada and more recently in England Child Death Review Pilot

4. Serious Case Reviews • Serious Case Review • All parts of the UK have similar processes for reviewing deaths from child abuse and neglect • Statutory obligation of LSCBs to undertake a serious case review • However this is limited by criteria, i.e. abuse or neglect must be known to be a factor or suspected; or a child must have committed suicide; or has been killed by a parent with a mental illness • Identifies lessons to be learned from inter-agency working Child Death Review Pilot

5. Child Death Review • Key Purpose • To conduct a comprehensive review of child deaths, to better understand how and why children die, and use the findings to take action that can prevent other deaths and improve the health and safety of children. Child Death Review Pilot

6. England • In England Child Death Reviews were introduced as a Statutory requirement under the Children Act 2004; started about three years ago. • Local Safeguarding Children Boards took the lead in this multi-disciplinary process. • Funded for a period of 3 years (up to March 2011) Child Death Review Pilot

7. England – Pros/Cons • Legislative obligation for LSCBs to review all child deaths 0-18 years • Development of Rapid Response Team to all unexpected child deaths • Health driven • Local reviews undertaken • Area specific - No national review • Impedes information sharing on a National basis • Individual reviews rather than thematic reviews are undertaken • Limits the ability to identify trends or themes Child Death Review Pilot

8. What’s happening in Wales? In 2008, the Welsh Assembly Government agreed to support a Child Death Review Pilot in Wales • Population base of LSCBs is significantly less than the recommended 500,000 for child death review • Not a legislative process for LSCBs to review all child deaths Child Death Review Pilot

9. All Wales Child Death Review Pilot • Pilot study from July 2009 to extended to March 2011 • Establishment of National Child Death Review Team • Team Members • Clinical Lead (Prof J Sibert) • Manager (Beverley Heatman) (previously Caroline Busby until March 2010) • Support Officer (Lucy Wood) • Designated Doctor - Child Protection & Safeguarding Children (Dr A Naughton) • Team hosted by Public Health Wales • Review all child deaths 0-18 years • Pilot documentation • Data collection commenced October 2009 • All Wales database development Child Death Review Pilot

10. Objectives • Ascertaining all child deaths (0 to <18 years) • Establishing national reviews of deaths • Testing the feasibility of establishing local case discussions and reviews Child Death Review Pilot

11. Ascertainment • Data is currently being collected using standard form [Form A] (based on the Form in England, though these forms are being revised in line with the information was are identifying as required) • Information relating solely to deceased • Not subject to Data Protection Act, but duty of confidentiality remains • Started in full October 1st 2009 • So far we have had identified 193 child deaths through various sources since commencement of the data collection. Child Death Review Pilot

12. Key Sources • LSCBs (received mainly from Registrars) -variable response • Office of National Statistics (ONS) • Clinicians including Welsh Paediatric Surveillance Unit • SUDI meetings • Coroners Rule 57a issued in Wales with effect of 1 April 2010 • More recently, information is being cross matched with Patient Episode Database Wales (PEDW) and Welsh Demographics Service (WDS) Child Death Review Pilot

13. Issues encountered • Data Protection/Confidentiality • Information related to the deceased and therefore not subject to Data Protection Act, however, duty of confidentiality remains • No dedicated resource for process within organisations • Informing Families • Telling families that limited information about their child’s death will be collected Child Death Review Pilot

14. Informing Families • Expected • Basic information provided through hospital bereavement processes • Routine information collected, leaflet provided • Duty Consultant Paediatrician • Unexpected • More detailed information provided at start of SUDI process by professional identified at initial meeting • Likely to be subject to review Child Death Review Pilot

15. PRUDiC A document detailing the “Procedural Response to Unexpected Death in Children” is under development and is expected to supersede the current “SUDI protocol” Child Death Review Pilot

16. National Reviews • Panel • Fixed core membership including representatives from health, social care, police • Option to co-opt other professionals/individuals who can make a contribution • Purpose • Identify patterns or trends emerging locally or nationally • Focus on findings of reviews and preventative factors • Outcome • Variable dependant on the theme being reviewed and the engagement required • Multi-sectorial workshops to produce action plans for dissemination and implementation Child Death Review Pilot

17. National Reviews • Current Reviews: • Suicides or apparent suicides (report pending) • SUDIs and Overlaying (report pending) • Quad Bikes & Mini-motos (report pending) • Future reviews planned • Medical deaths where there are lessons for all of Wales • Asthma • Intestinal failure • We differ in our approach from England as we want to consider deaths from similar causes. Child Death Review Pilot

18. Suicides 2006-2009 • 21 Cases were reviewed in total • Consent was obtained to review only a minority of these, however some very important illustrative points were identified. • First panel meeting held in March 2010; with a further panel meeting held in June 2010 • Agreed to use publicly available information relating to other cases • Multi-sectorial workshop is being arranged to share the conclusions of the National panel and to develop recommendations and an action plan. Child Death Review Pilot

19. SUDIs and Overlaying • We used information available through transcripts of the Inquests from Cardiff & the Vale areas for 2009. • We obtained permission of the Coroner Ms Hassell • Two panel meetings have been held; one in June 2010 and another in September 2010. Child Death Review Pilot

20. Quad Bikes & Mini Motos • Publicly available information was used • Eighteen deaths were identified across the UK (three of whom were <4 years) • Five females • Thirteen males • Eight deaths involving quad bikes • Ten deaths involving mini-motos • Higher incidence in Northern Ireland Child Death Review Pilot

21. Wales Pros/Cons • All Wales approach • Looks at the circumstances surrounding the death • Identifies preventable factors • Looks at all child deaths and aggregates the information • Produces recommendations for prevention of future deaths Child Death Review Pilot

22. Wales – Pros/Cons • Consent has to be obtained for 3rd party information • Local Safeguarding Boards are not obliged to assist in the process Child Death Review Pilot

23. Next Steps • Report is being submitted to the Welsh Assembly Government for an all Wales National Child Death Review programme to continue following completion of the pilot • Our primary and key recommendation will be that the Welsh Assembly Government must facilitate making this a statutory obligation Child Death Review Pilot

24. Future for the pilot • Wider stakeholder engagement • Integration of PRUDiC with Child Death Review Process • Document development • Database development • Suicides Multi-sectorial workshop to develop recommendations and action plan • Await outcome from WAG Child Death Review Pilot

25. Thank you • Any questions? Child Death Review Pilot