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

Introduction Why Jason Died Child Death Review Process

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

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

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

What is an unexpected death? Child Death Review Process 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

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

Neonatal Deaths Child Death Review Process 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

Unexpected Deaths in Hospital Child Death Review Process 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

Unexpected Deaths in the Community Child Death Review Process 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

Unexpected Deaths in the Community 2 Child Death Review Process 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

Rapid Response Child Death Review Process 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

Rapid Response in Surrey Child Death Review Process 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

Rapid Response in Surrey 2 Child Death Review Process 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

Child Death Review Child Death Review Process 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

Child Death Review 2 Child Death Review Process 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

Child Death Review 3 Child Death Review Process 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

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

Categories of Deaths Child Death Review Process 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

Categories of Deaths 2 Child Death Review Process 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

Child Death Overview Panel Child Death Review Process 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

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

CDOP Functions Child Death Review Process 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

CDOP Functions 2 Child Death Review Process 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

Surrey Child Deaths 2011 - 2012 Child Death Review Process Surrey Children Non-Surrey Children Total Child Deaths <1 month 31 18 49 1 month to 1 year 11 4 15 1 year to 4 years 3 7 5 years to 9 years 1 10 years to 14 years 15 years to 17 years 5 Total 56 27 83 Child Death Review Process

Resident Surrey Child Deaths 2011 - 2012 Child Death Review Process Male Female <1 month 17 14 1 month to 1 year 5 6 1 year to 4 years 2 5 years to 9 years 1 10 years to 14 years 15 years to 17 years Total 30 26 Child Death Review Process

Unexpected Surrey Child Deaths 2011 - 2012 Male Female Total <1 month 1 2 1 month to 1 year 3 4 7 1 year to 4 years 5 years to 9 years 10 years to 14 years 15 years to 17 years 8 9 17 Child Death Review Process

Child Death Reviews 2011 -2012 Child Death Review Process 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

Child Death Reviews 2011 -2012 Child Death Review Process 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

Child deaths 2011-2012 by category and sex Category of death Male Female Deliberately Inflicted injury, abuse or neglect Suicide or deliberate self inflicted harm Trauma and other external factors 2 Malignancy Acute medical or surgical condition 3 Chronic medical condition 1 Chromosomal, genetic and congenital abnormalities Perinatal / Neonatal event 10 7 Infection Sudden unexpected, unexplained death Awaiting categorisation (9: Neonatal, 3: waiting for post mortem results) 6 8 Total 30 26 Child Death Review Process

Preventable Deaths Child Death Review Process 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

Learning Child Death Review Process 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

Learning 2 Child Death Review Process 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

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