CEMACH Child Death Review

1
CEMACH Child Death Review
A Pilot Study
Gale Pearson Clinical Director Child Health
Enquiry
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Entry to the Study

• Child (28 days to 17 years 364 Days)
• Region of Death (or residence)SW, Wmids, NE,
  Wales, Northern Ireland
• Death during calendar year 2006

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Panel enquiry

• Sample based upon age and geographical area
• Age Bands28-364 days, 1-4yrs, 5-14yrs, 15-17
  yrs
• Anonymised records in remote locations

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Results
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2.47 deaths per 10,000 children
Wales 170
South West 228
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Age Distribution
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Number of Deaths Comparison with Neonates
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Age at Death
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Child Death Rate per 10 000 Live Children
Children Aged 28 days to 17years 364 days
10
Child Death Rate per 10 000 Live Children
Children Aged 15 - 17 years 2006
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Ethnicity
12
Deprivation
13
Non Natural Deaths
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Road Traffic Accident Age of child and time of
accident

20
18
16
14
12
Number of deaths
10
8
6
4
2
0
0700-0959
1000-1459
1500-1659
1700-2159
2200-0659
Time of collision
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Suicide
Age
-
specific suicide rate per 100,000 aged 11
-
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Data Source
Age
-
specific suicide rate per 100,000 aged 11
-
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Data Source
Northern
Wales
England
Northern
Wales
England
Ireland
Ireland
3.6
1.5
0.3
ONS 1995

2004
3.6
1.5
0.3
ONS 1995

2004
5.6
2.2
0.9
CEMACH Child Death
5.6
2.2
0.9
CEMACH Child Death
(3.02

10.42)
(0.98

4.9)
(0.52

1.69)
Review
(3.02

10.42)
(0.98

4.9)
(0.52

1.69)
Review
Not all of England

data from SW, WMids and NE only
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Primary Care Study

• Core data on primary care 769/957
• 43 seen by G.P. in the 3 months before death
• 76 cases from panels
• 92 cases from North East

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Primary Care Study
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Multidisciplinary Panels

• 126 / 957 13 of our sample (4 total)
• Standardised composition
• Relevant experts
• Standardised reporting Tool
• Practical Approach

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Avoidable Factors

• Avoidable
• Failures in direct care
• Latent, organisational or other indirect
  failure(s)
• Failure of design, dilapidation, inadequate
  maintenance
• Potentially avoidable
• At a higher level (e.g. political violence, war,
  terrorism, crime, homicide)
• No agency involved directly or indirectly
• Intrinsic factors (e.g. an acquired disease with
  a known high mortality)
• Potentially modifiable factors extrinsic to the
  child
• Causal pathway traces back to antepartum or
  intrapartum events
• Unavoidable
• Unmodifiable factors extrinsic to the child (e.g.
  lightning)
• Undiagnosed conditions presenting with a lethal
  event
• Planned palliation for lethal disease

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Panel Conclusion Feasibility of Confidential
Enquiries in Children

• Notification data alone is sufficient to detect
  most non natural deaths
• Scrutiny by an expert / panel required to detect
  avoidable factors

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Panel Conclusion Feasibility of Confidential
Enquiries in Children

• 119 / 126 panels sufficient information to
  assess avoidable factors
• 26 of cases contained avoidable factorsMost
  frequently an identifiable failure by any agency
  (including parents) with direct responsibility
  towards the child
• 43 of cases contained potentiallyavoidable
  factors

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Panel Conclusion Feasibility of Confidential
Enquiries in Children

• Avoidable factors were less common when life
  limiting illness was present
• Half of the cases where avoidable factors were
  found would not have been classified as
  unexpected deaths using the Working together
  definition

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Panel Conclusions Failure to recognise serious
illness in children

• History
• e.g. A potentially lethal overdose sent home
  from AE
• Examination
• e.g. A child with a fever of over 40OC coughing
  up blood dismissed as hysterical and sent home,
  died later

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Panel Conclusions Failure to recognise serious
illness in children

• Failure to recognise complications
• Delay in referral / treatment

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Panel Conclusions Failure to recognise serious
illness in children

• Common themes (c.f. Health Care Commission 2007)
• Junior staff untrained in paediatrics
• Not supervised by paediatric trained staff
• Care in non paediatric areas
• Failure to follow published guidance
• NICE guidance
• NSF for Children

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Panel Conclusions Missed Appointments

• Trust Policies Targets for DNA

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