CHILD DEATH OVERVIEW PANEL Each death of a

CHILD DEATH OVERVIEW PANEL Each death of a child is a tragedy for his/her family Objective of the child death review process • To learn lessons to improve health, safety and wellbeing of children • To prevent further child deaths 1

Panel is multi-disciplinary, multi-agency, with permanent core membership Nurses Paediatricians (SUDI) Public Health Consultant HSCB Manager, Project Manager Coroner’s Assistant Police Social Worker • • • Review is ‘paper based’ using information from those involved in care of the child before and immediately after death; and other sources, e. g. Coroner Regular meetings (minimum quarterly) Review professionals responses to death of a child, review any environmental, social, health and cultural aspects to consider how deaths might be prevented in future 2

• Determine if death was v. Not preventable v. Potentially preventable (modifiable factors may contribute to the death), Family, environment, parenting capacity, service provision • Make recommendations to the LSCB or other relevant bodies to ensure prompt action to prevent further deaths • Identify patterns or trends and report these to LSCB 3

Rapid response to unexpected death • Death not anticipated as a possibility 24 hours before death • Unexpected collapse or incident leading to or precipitating, the death • Multi-agency team of nurses, doctors, police and social workers • All professionals share information related to child possibility of anything unlawful and to initiate ongoing support to family 4

2009/10 80 deaths Of 41 reviewed (21 boys, 20 girls) 35 not preventable 5 preventable (modifiable factors) 1 inadequate information (23 children were aged under one) 8 expected deaths 22 unexpected 11 not known 5

Main Causes were • • Suicide, deliberate self-harm Chronic medical conditions Perinatal/neonatal events Infection 6