Child Death Review Process

1. Child Death Review Process By Paul Wright Designated Doctor for Child Deaths in Surrey Child Death Review Process

2. Introduction Why Jason Died Child Death Review Process

3. Introduction • Introduced in Working Together 2006 • Statutory since 1st April 2008 • Consists of two interrelated processes for reviewing Child Deaths

4. Introduction • Introduced in Working Together 2006 • Statutory since 1st April 2008 • Consists of two interrelated processes for reviewing Child Deaths

5. Introduction 2 • 1. Rapid response by a group of key professionals who come together for the purpose of enquiring into and evaluating each unexpected death of a child • 2. An overview of all child deaths up to the age of 18 years (excluding both those babies that are stillborn and planned terminations of pregnancy carried out within the law) in the LSCB area, undertaken by a panel Child Death Review Process

6. What is an unexpected death? • In this guidance an unexpected death is defined as the death of an infant or child (less than 18 years old) which: • Was not anticipated as a significant possibility for example, 24 hours before the death; or • Where there was a similarly unexpected collapse or incident leading to or precipitating the events which led to the death Child Death Review Process

7. Processes for Unexpected Deaths • There are two separate processes followed unexpected deaths: • 1. Neonates on Neonatal Unit • 2. All other Children Child Death Review Process

8. Neonatal Deaths • We consider Neonatal deaths to include all Children born prematurely • All Children born at term, or near term will follow the normal Child Death Processes • These Deaths do not initiate a Rapid Response • Information is collated and reviewed by a co-opted Consultant Neonatologist Child Death Review Process

9. Unexpected Deaths in Hospital • Normal Hospital procedures should take place • Families should be allocated a member of Hospital Staff to remain with and support them • Hospital Staff should contact the Coroner • Hospital Staff should contact the Child Death Review Coordinator to inform them of the Child Death Child Death Review Process

10. Unexpected Deaths in the Community • These Children should normally be taken to an A&E department rather than the mortuary • There are times when it is clearly inappropriate to take a Child to A&E • Resuscitation should always be initiated unless clearly inappropriate • The Child should be examined by a Consultant Paediatrician and a detailed and careful history of the events taken Child Death Review Process

11. Unexpected Deaths in the Community 2 • Hospital Staff should contact the Coroner • A&E should then contact the Child Death Review Coordinator to inform them of the Child Death • Appropriate support should be offered to the family including where available: • Bereavement Counsellor • Hospital Chaplin • Faith Leader Child Death Review Process

12. Rapid Response • Each LSCB has set up its own procedures for providing rapid response • Some LSCBs have pooled resources so that rapid response is carried out across a number of LSCBs Child Death Review Process

13. Rapid Response in Surrey • Led by Rapid Response Nurse – Liz Seymour • She will: • Make contact with the family • Explain to them the Child Death Process • Take the History of events leading to the Death • Present any questions or concerns that they may have • Will advise the family of where to access support • Feedback to the family any results of the investigation Child Death Review Process

14. Rapid Response in Surrey 2 • Rapid Response should take place within a week of the death • However this can be delayed if the family wish it to be • There are occasions when Rapid Response is inappropriate Child Death Review Process

15. Child Death Review • This is a set review to bring together information about the events leading up to a Child’s death • It is a multi-professional meeting. Those who are generally invited include: • Named Nurse • General Practitioner • School Nurse/ Health Visitor • Hospital Paediatricians Child Death Review Process

16. Child Death Review 2 • Other Professionals invited: • Hospital Nursing Staff • Tertiary Consultants • Social Care • Police • School • Educational Psychologist • Ambulance Staff • Coroner’s Officer • Other Professionals may be invited dependant on review Child Death Review Process

17. Child Death Review 3 • Aims of the Review: • To look at the events leading to the Child’s death • To look and see if any changes in management may have prevented the death • To get a holistic picture of the Child • To look at the support the family are receiving • To look at the preventability of the death • To categorize the death • To consider referral for an SCR Child Death Review Process

18. Preventability • Government Statistics consider 3 categories which are reported on at the end of the year: • Unpreventable • Partially Preventable • Preventable Child Death Review Process

19. Categories of Deaths • This Classification is hierarchical: where more than category could reasonably be applied, the highest up the list should be marked • 1. Deliberately inflicted injury, abuse or neglect • 2. Suicide or deliberate self-inflicted harm • 3. Trauma and other external factors • 4. Malignancy • 5. Acute Medical or Surgical Condition • 6. Chronic Medical Condition Child Death Review Process

20. Categories of Deaths 2 • 7. Chromosomal, Genetic and Congenital anomalies • 8. Perinatal/ neonatal event • 9. Infection • 10. Sudden Unexpected, Unexplained death • Often categorization of the death has to wait until the inquest has taken place Child Death Review Process

21. Child Death Overview Panel • This is a Statutory Panel which meets every 2 months in Surrey • It is chaired by an Independent Chair • It is a multi-professional panel Child Death Review Process

22. Child Death Overview Panel 2 • Representatives include: • Health • Social Care • Police • Ambulance • Coroner’s Office • Voluntary Sector (CHASE Hospice) • Public Health • Risk Manager, NHS Surrey Child Death Review Process

23. CDOP Functions • CDOP has many functions which are defined in Working Together 2010 • These include: • Determining Preventability on all deaths • Collecting and collating the minimum data set on each child • Evaluating the data set and identifying lessons to be learnt or issues of concern Child Death Review Process

24. CDOP Functions 2 • Reviewing specific cases in detail • Referring to the Chair of LSCB if there are grounds to undertake further enquiries e.g. SCR • Monitoring support and assessment services to the families of children who have died • Identifying any Public Health issues • Co-operating with regional or national initiatives Child Death Review Process

25. Surrey Child Deaths 2011 - 2012 Child Death Review Process

26. Resident Surrey Child Deaths 2011 - 2012 Child Death Review Process

27. Unexpected Surrey Child Deaths 2011 - 2012 Child Death Review Process

28. Child Death Reviews 2011 -2012 • 17 Cases reviewed between April 2011 and March 2012 • Of these: • 4 Sudden Unexpected Death in Infancy • 4 acute medical or surgical conditions including 2 SUDEPs • 3 infections • 1 drowning • 1 equipment failure • 4 awaiting categories Child Death Review Process

29. Child Death Reviews 2011 -2012 • 3 Deaths were referred to the Serious Case Review Group • Of these: • One went to Serious Case Review • One to Case Review • One did not proceed Child Death Review Process

30. Child deaths 2011-2012 by category and sex Child Death Review Process

31. Preventable Deaths • 6 Preventable Deaths between April 2011 and March 2012 • 1 died overseas • 2 died of SIDS although evidence of co-sleeping and drug/ alcohol use • 1 drowning in the bath • 1 due to overwhelming infection not recognized by medical professionals • 1 due to equipment failure Child Death Review Process

32. Learning • Learning points to be considered: • There have been a number of deaths associated with co-sleeping, and with a history of alcohol and drug use. CDOP feels that a co-sleeping campaign is required • There are still issues about the notification of deaths in children who are not taken to A+E, i.e. the child is pronounced dead at the scene • Listening to the parents about feeding problems in newborns Child Death Review Process Child Death Review Process

33. Learning 2 • Additional Learning Points: • A need to examine neonatal deaths in detail • Lack of minimum standards for laboratory investigations after child deaths in Surrey Child Death Review Process

34. Thank you