Child Death Review Process for South Tyneside

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Child Death Review Process for South Tyneside
9th September 2008 9.15 11.15 17th September
2008 9.30 11.30
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Introduction

• From 1st April 2008-
• New statutory LSCB functions regarding child
  deaths
• Collecting and analysing information about the
  deaths of all children in the area with a view to
  identifying
• any matters of concern affecting the safety and
  welfare of children in the area of the authority,
  including any case giving rise to the need for a
  serious case review.
• any general public heath or safety concerns
  arising from deaths of children.
• Putting in place procedures for ensuring that
  there is a coordinated response by the authority,
  their LSCB partners and other relevant people to
  an unexpected death of a child.

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The Journey
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Origins of the Child Death Review Process

• There are longstanding arrangements for reviewing
  the deaths of neonates (0 -27 days) within
  Health.
• CEMACH 2003 (Confidential Enquiry into Maternal
  and Child Health).
• The child death review process has learned
  lessons from and built on these arrangements.

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Number of Deaths Comparison with Neonates 2006
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(No Transcript)
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Immediate cause of neonatal deaths (birth to 27
days inclusive)
a NEC necrotising enterocolitis
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Provisional Categorisation of Deaths 28 days to
18th birthday
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Key Findings

• Over 550, 000 children in the North East, around
  29,000 births each year
• In 2007 238 deaths in childhood (231 in 2006)
• In 2007 37 (87/238) of the deaths before 28 days
  of life (neonatal deaths) in 2006 48 (111/231)
• In 2007 57 (135/238) of the deaths occurred
  before the child's first birthday. In 2006 67
  (154/231)

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General Message

• There may be little that can be learned from an
  individual child death or by comparing simple
  child death rates.
• Lessons are best identified from examining the
  complete picture in terms of cause of death,
  geography, age, social factors etc.

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QA
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Structure
Executive
Management Group
Policy and Procedure
Performance Management and Evaluation
Case Review
Training
Reducing Accidents, Self Harm and Avoidable
Admissions
Our Children and Young People
Staying Safe
Safer Parenting
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The Safeguarding Childrens Board Place in the
wider partnership arrangements

Local Strategic Partnership (Local Area Agreement)

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Select Committee
Safeguarding Children Executive Board
C YP Alliance Board
LSCB Sub-structure
Alliance Sub - Structure
Member Agencies
Community Voluntary Sector
Practitioners
Public
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Case Review

• Membership multi agency
• Chaired by Designated Nurse Child Protection
• Agencies include Police, Local Authority,
  Probation and NSPCC
• Role and Function
• Serious Case Review
• Local Child Death Review Panel

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QA
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Death of an Infant or Child
Expected
Unexpected
Interagency Rapid Response 
Suspicious?
Standard Bereavement Care
Child Protection / Criminal Investigation
Final Case Discussion
Coroners Inquest
Information Gathering
Death Registration
Serious Case Review
Child Death Overview Panel
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CHILD DEATH REVIEW PROCESS

• Rapid response to unexpected death by key
  professionals
• Review of every childs death
• An overview of all child deaths.

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Child Death Review Process

• The desired outcomes are
• to have a clear understanding of each child
  death.
• for this information to be collated, analysed and
  considered in overview.
• to use the information to develop practice to
  reduce avoidable deaths, improve child welfare
  and safeguard children.

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1. Rapid Response

• Health / Police will determine whether the death
  is to be treated as expected/unexpected.
• Health / Police will carry out their normal
  duties to determine if the death is due to
  health issues/ accident/suspected crime, and what
  are the circumstances of the death.
• The Rapid Response is about
• securing evidence
• gathering immediate information (police
  investigation)
• Information is needed for the Local Review of the
  death

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2. Local Review Process

• 3 key agencies Health, Police, Local Authority
  these are involved in all reviews.
• Other agencies such as Fire Service, Youth
  Offending may be involved as appropriate.
• There will be a lead agency for each death. This
  will be determined by the nature of the death.

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Unexpected deaths

• Relevant agencies alerted
• Lead agency identified
• Agencies gather and share information
• Multi agency case discussion held within 5 -7
  days after the death
• Subsequent meeting tracking the result of the
  post mortem

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Expected deaths

• Agencies informed
• Lead agency identified
• Agencies gather and share information
• No meeting required unless requested by lead
  agency
• For both expected and unexpected deaths
  information is collated for local child death
  panel (case review sub group).

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Neonatal deaths

• Child dies before 28 days or without ever leaving
  hospital
• Local health professionals conduct review of
  death
• Report provided to the overview panel
• Report provided to CEMACH process

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QA
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Child Death Review Overview Process
RMSO Notifications
Coordinator
Local Review Team
Local Review Team
Local Review Team
Child Death Overview Panel (meets 4 x year)
Reviews of neo-natal deaths
Sunderland LSCB
Gateshead LSCB
South Tyneside LSCB
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Child Death Overview Panel

• Population over 500,000
• Sub regional arrangement
• RMSO
• Child Death Review Coordinator
• Reports to each LSCB to action

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Purposes of Child Death Review

• Collecting and analysing information about each
  death with a view to identifying-
• (i) Any case giving rise to the need for a
  serious case review
• (ii) Any matters of concern affecting the safety
  and welfare of children in the area of the
  authority
• (iii) Any wider public health or safety concerns
  arising from a particular death or from a pattern
  of deaths in that area

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Other Issues

• Proper management of unexpected childhood death
  involves a thorough and systematic yet sensitive
  inter-agency approach
• Coroners role and function
• Supporting the family

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Conclusion

• Factors contributing to childhood deaths
• Factors intrinsic to child
• Family environment
• Parenting capacity
• Service provision and need

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Preventabilty

• Preventable
• Identifiable failures in the childs direct care
• Latent environmental or systemic failures
• Potentially preventable
• More distal factors affecting the child or family
• Potential interventions in a causal pathway
• Not preventable
• Death due to unmodifiable intrinsic factors
• Undiagnosed asymptomatic lethal conditions
• Planned palliation
• Unmodifiable or unpredictable extrinsic factors

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Taking action to prevent child deaths

• Strengthening individual knowledge and skills
• Promoting community education
• Training providers
• Advocacy health promotion
• Changing organisational structures and practice
• Mobilising communities
• Influencing policy and legislation

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Principles underlying the overview of all child
deaths

• Every childs death is a tragedy
• Learning lessons
• Joint agency working
• Positive action to safeguard promote the
  welfare of children
• Sensitive and supportive to families

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Professional confirms fact of death (Paediatrician
/Coroner)
Rapid Response
Abuse and/or neglect suspected
Serious Case Review
Unexpected Death Yes/No
Who will notify (Coroner, Police, LA Children
Families and Regional Maternity Survey Office
(RMSO)
RMSO notifies
Local Child Death Review Co-ordinator who informs
identified contact in relevant area
Gateshead
Sunderland
South Tyneside LSCB
Information flow dependent on possible ongoing
Police investigation
The key contact in each area will ensure there is
an immediate discussion between the key agencies
involved with the child to agree what happens
next/who will do what?
Serious Case Review
Multi-agency discussion in each area. 5 7 days
after death
Abuse and/or neglect suspected.
Local Review in each area No later than 12 weeks
after death.
Serious Case Review
Abuse and/or neglect suspected.
Reviews of neo-natal deaths
Child Death Overview Panel covering Gateshead,
Sunderland and South Tyneside.
Gateshead LSCB
Sunderland LSCB
South Tyneside LSCB
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Final QA