1. The Child and Youth Mortality Review Committee The work we do to reduce avoidable deaths

2. The CYMRC  who we are Established under the NZ Public Health & Disability Act 2000. An independent committee reporting directly to the Health Quality & Safety Commission. One of four permanent mortality review committees.

3. The CYMRC  what we do Reduce preventable deaths through an interdisciplinary and interagency approach. Local analysis and review through our local child and youth mortality review groups (LCYMRGs). Provide annual national reports to the Commission. Make recommendations about local and national actions to reduce avoidable deaths.

4. LCYMRGs Multi-agency. Multi-disciplinary. Members attend with support of their agencies (links to CYMRC’s agreements with agencies). Consistent processes and understanding of the process. Local involvement and ownership. Confidentiality.

7. Example of a LCYMRG (Example: Waikato LCYMRG) Established in 2005, Police, Child Youth and Family, St John, Plunket, Ministry of Education, Quality and Risk, paediatricians, Whakawhetu (formerly Māori SIDS), mental health services, child protection, local Iwi representative, Population Health, primary care and maternity care. Group meets once a month for 2.5 hours. Representatives bring information discussed openly in ‘no fault’ context. Recommendations are agreed and reported. Representatives take ownership of relevant recommendations and report progress to the group.

8. Local review: A core quality improvement action for all DHBs? Death is the ‘ultimate adverse child outcome’. Many deaths are preventable. Without review preventable deaths will continue unabated. –Trends across the country go unrecognised. –Tragic mistakes repeated. LCYMRGs review the events surrounding each death and make recommendations for change. Timely, accurate reporting of death data and freedom from fear of legal proceedings. The process is invested with power to obtain information and to require action when needed.

9. Key findings from the 11 th data report (2010–14 data)

10. How are our kids dying? Data is for 2010–14

11. Mortality varies by age and ethnicity Data is for 2010–14

12. Mortality varies by age and ethnicity Data is for 2010–14

13. Poverty causes more than just hardship Data is for 2010–14

14. The main causes of death change with age Data is for 2010–14

21. The good news The number of deaths overall is reducing.

25. Special report: Alcohol related deaths (2005–07) Key findings and themes: Alcohol involvement was highest in motor vehicle, assault and fall categories. Males were over-represented in all of the deaths. Alcohol consumption occurred in a variety of settings: at domestic addresses, at parties or in public places Intoxicated parents or caregivers have caused or contributed to some deaths of infants and children. Alcohol consumed was mostly beer, wine, and spirits.

26. Special report: Alcohol related deaths (2005–07) Some key CYMRC recommendations: Enforcement of the zero BAC for young and novice drivers. Limit the availability of alcohol and make alcohol less attractive. Initiatives to broaden the public’s understanding of risks of combining alcohol and hazardous environments. Police should be mandated to test for alcohol- related impairment whenever a child or young person suffers a serious injury or fatality, regardless of location.

27. Special report: Low speed runover mortality (2002–08) Key findings and themes: Three to five children die each year, mostly under the age of five years, from being run over by vehicles manoeuvring at low speed Four protective elements can protect a child from being run over: –Children being physically separated from areas where vehicles may move. –Children being under direct adult supervision. –The driver seeing the child. –The driver being alert to the possibility of a child being close to the vehicle.

28. Special report: Low speed runover mortality (2002–08) Key CYMRC recommendations related to: environmental change (eg, fencing driveways, safe play spaces, shorter driveways, keep cars out of driveway, child gates/doors) regulations and guidelines initiatives to increase driver awareness education of caregivers – driveway safety messages and resources.

29. www.safekids.nz Check for me before you turn the key

30. Special report: Unintentional suffocation, foreign body inhalation and strangulation (2002  09) Key findings and themes: Main causes of death: Accidental suffocation and strangulation in bed (highest during the first year of life) – overlaying and wedging. Other accidental suffocation, strangulation and threats to breathing (highest in preschool-age children). Inhalation of food or other objects causing obstruction of respiratory tracts. Males more likely to die than females.

31. Special report: Unintentional suffocation, foreign body inhalation and strangulation (2002  09) CYMRC recommendations mainly related to safe sleep: provision awareness strategies product safety research.

32. Special report: Unintentional suffocation, foreign body inhalation and strangulation (2002  09) Consistent and persistent safe sleep practices: Māori community-driven solutions (culturally appropriate, appealing, possible, easy). Safe sleep for infants reprioritised: –Model and support good practice at every opportunity. –Antenatal preparation. –Enable safe sleep – make doing the right thing easy (wahakura, pepi-pods) –Whole-of-society priority. Every baby needs a sober caregiver.

33. Special report: Unintentional suffocation, foreign body inhalation and strangulation (2002  09) Unbroken journey of safe sleep support: Antenatal – natal – postnatal – infant 1.Needs assessment 2.Planning – with family 3.Action - every baby has a safe place to sleep and it is used.

34. Special report: Unintentional suffocation, foreign body inhalation and strangulation (2002  09) A safe sleep is: free from other people who might lie over the baby free from gaps that could trap or wedge the baby firm flat free from objects that might cover the face or cause strangulation or the baby’s head coming forward free to breathe free from tobacco smoke.

35. Special report: Unintentional deaths from poisoning in young people (2002  08) Key findings and themes: 202 deaths (29 per year on average). Deaths due to poisoning were the second most common cause of unintentional deaths and deaths of undetermined intent. Gases and volatile liquids were the single largest substance group causing poisoning (34 percent). Opioids 32 percent. Other substances 33 percent.

36. Special report: Unintentional deaths from poisoning in young people (2002  08) Key CYMRC recommendations related to: reducing attractiveness and demand reducing access increased peer and community awareness improving screening and intervention establish a clear lead agency promoting community messages.

37. Special report: Motorcycle, quad bike and motorised agricultural vehicle use (2002  12) Key findings and themes: Recreational use of off-road vehicles is the second most common cause of recreational death for children in New Zealand. During 2002–12, 33 New Zealand children aged 0–15 years died from using off-road vehicles in both on- and off-road settings. On average, three children aged 0–15 years die annually while driving or riding on off-road vehicles in New Zealand.

38. Special report: Motorcycle, quad bike and motorised agricultural vehicle use (2002  12) Key CYMRC recommendations related to: rules for under-16s not operating adult- sized off-road vehicles bike safety training programmes for young people improved vehicle safety mechanisms on quad bikes better use of safety practices and guidelines.

39. Special report: Mortality and morbidity of pertussis in children and young people (2002–14) Key findings and themes: Eight deaths from pertussis (seven were infants under 3 months with no or inadequate protection against pertussis). 1515 hospital admissions. Infants aged under three months most at risk. Māori and Pacific infants, children and young people were more likely to be hospitalised.

40. Special report: Mortality and morbidity of pertussis in children and young people (2002–14) Key CYMRC recommendations related to: more equitable, no-cost coverage of the pertussis booster vaccination during pregnancy education resources about the benefits of maternal pertussis immunisation awareness-raising about importance of pertussis booster vaccination in the third trimester removal of barriers to immunisation service access for pregnant women.

41. Drownings 2003  07 Age group 0–4 years (34 deaths) Age group 5–14 years (21 deaths) Age group 15–24 years (54 deaths)

42. Drownings 2003  07 Age group 0–4 years (34 deaths) Age group 5–14 years (21 deaths) Age group 15–24 years (54 deaths)

43. Drownings 2003  07 Age group 0–4 years (34 deaths) Age group 5–14 years (21 deaths) Age group 15–24 years (54 deaths)

44. Recommendations/ Actions/Follow-up For each agreed system issue, identify: what actions/recommendations maybe helpful (and consider any unintended negative consequences) at whom each recommendation is aimed who should take the recommendation forward what follow-up is reasonable/possible any further information needed before closing off the case.

45. For ourselves (eg, system and process development). ‘Plug’ our information to an existing ‘machine’ (eg, slow speed runover and safe kids). Cultivate allies as work progresses (eg, alcohol and transport legislation changes). Clear and implementable by single body (eg, pyjama fire safety labelling). Aligned to other government programmes (eg, newborn enrolment). Tight loose tight? (eg, engaging DHBs to make sure SUDI matters) Recommendations that work

46. So far  104 –Achieved - 31 –Partially achieved - 52 –Not achieved - 21 What fails? – Vagueness, eg, X needs to happen – ‘Motherhood and apple pie’ – ‘Education should occur…’ – Solutions without clear problems Although some not achieved, workarounds have been done, eg, bath seats. CYMRC recommendations

47. National Pol47a for SUDI cases. Resource development for SUDI awareness. River safety/environments. Isolated rural communities have identified local first aid providers. Support/Options for schools with at-risk youth in terms of counselling. National guidelines for the transportation of deceased infants. Recommendations and outcomes