CHILD DEATH REVIEWS Child deaths at Bristol Royal Infirmary Kennedy Report into Infant Deaths Laming Inquiry – Victoria Climbie Children Act 2004 Working Together to Safeguard Children

Working Together to Safeguard Children 2006 Chapter 7 Investigation of Unexpected deaths in children – Rapid Response Overview of all child deaths Chapter 8 Serious Case Reviews

LCSB Functions - Child Death Reviews 1.To collect and analyse information about each death with a view to identifying: Cases giving rise to the need to undertake SCRs Matters of concern affecting the safety and welfare of children Wider Public Health and safety concerns arising from individual deaths and also from patterns of deaths 2 To put in place procedures for ensuring a coordinated response by partner agencies to unexpected deaths.

Unexpected Deaths – Working Together definition The death of a child that was not anticipated as a significant possibility 24 hours before the death OR Where there was a similarly unexpected collapse leading to or precipitating the events that led to the death

Investigating Unexpected deaths- Rapid response process 1.Immediate Response Detailed history Arrange support for parents Liaison with police if concerns death is suspicious Notification of coroner Detailed clinical history/examination/investigations Check Children’s Social Care

Rapid response process ctd……….. 2.Next few hours Information gathering Report to pathologist carrying out PM Handover to SUDIC Paediatrician/team Consider visit to place of death

Rapid response process ctd……….. 3.Visit to place of death??? NOT if a possible crime scene – unless with agreement of Police NOT to sites of RTAs Visit MUST add clear value Recognition that Community Nurses – esp HVs – have most expertise in assessing children’s home environments Paramountcy of safety of professional

Rapid response Process ctd………. 4.Discussion at 5-7 days Usually by telephone Include: –Pathologist –Police –Children’s Social Care –Paediatrician/Emergency Medicine –Others as appropriate 28 Day Report to Coroner

Rapid response Process ctd…….. 5.Case Discussion Meeting 8-12 weeks after the death Chaired by SUDIC Paediatrician Involve GP/MW/HV/SN Paediatrician/other relevant clinicians Pathologist if possible Police CSC

Rapid Response Process ctd…… Purpose – Case discussion meeting To share information re COD/contributory factors including abuse or neglect Plan future care of the family Identify potential lessons Inform the Inquest Agree arrangements for providing information to parents Prepare report for Child Death Overview Panel

Child Death Overview Process All deaths from birth to 18 th birthday Paper exercise for information collection Panel – formal subcommittee of LSCB, accountable to Chair Population>500,000 ideally Panel – fixed core membership +/- co-optees Regular timely meetings Purpose – to review care plus identification of relevant factors Examine trends in child deaths in LSCB area

Function – C D O Panel Ref 7.55 in Working Together 1.Monitoring the Child Death Review processes inc SUDIC arrangements 2.Collating agreed MDS 3.Identifying lessons/issues of concern from individual cases 4.Referring to LSCB chair those cases where a SCR indicated 5.Informing LSCB chair and Coroner of any new information 6.Providing relevant information to those professionals involved with ongoing care of the family

Functions ctd……….. 7.Monitoring and advising SCB on training and resource issues for process 8.Indenitying Public Health and preventative issues and considering with DPH how best to address these 9. Co-operating with national inquiries – eg CEMACH

Process…………….. Information collection- deaths to be reported to LSCB nominee CEMACH data collection tool Panel discussion- analysis pro-forma Assess 4 domains and their applicability to the death Assess the preventability of the death Classify the death Summary of issues identified and actions agreed – at individual case and at population level