Child Death Reviews London Borough of Croydon

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Child Death ReviewsLondon Borough of Croydon

• Briony Ladbury Croydon PCT
• Dr Shade Alu Croydon PCT
• DI Tessa Philpott Met Police CAIT
• Peter Witchlow LB Croydon Childrens Services

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Setting - Up

• Priority in Croydon ACPC / CSCB since 2004 5
• Started to collect data relating to child deaths
• An attempt to meet 9.11.42 P 186 (Edition 2 of
  London Child Protection Procedures)
• The designated paediatrician should convene
  within 3 days of the childs death, a
  multi-agency discussion or planning meeting

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Our Understanding Now

• 3 distinct areas to develop

1.Fast Response
2. Post Death Meeting
3. Overview Panel
Underway v
In discussion ?
Not yet x
CSCB Multi Agency Chid Death Review Sub-Group
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Post Death Meetings

• Cases Notified

• Children who die in Hospital
• SCBU
• Paediatric Ward

• Children taken
• to Accident Emergency
• from a community location
• SUDIs
• Accidents
• RTIs
• Violence
• Suicides
• Unexpected Death/collapse

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Information Cascade

• Hospital staff contact
• Named Nurse CP (Acute)
• GP
• Mortuary
• Liaison HV
• Social Services
• Police (if not involved)
• OOH Child Protection Nurse On Call EDT
• Liaison HV
• Child Health Dept
• Named Nurse CP (Community)
• HV SN
• other community staff

• Named Nurse Contacts
• Designated Nurse
• Designated Nurse Contacts
• Designated Doctor
• SSD Child Protection Lead
• DI Police CAIT
• PCT Director
• LHA via SUI

Core members of Post Death Meeting
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Post Death Meetings

• All notifications entered onto data base
• Cascade protocol within 1 working day
• Decision made re post death meeting
• Meeting set up by SSD Child Protection Lead
• Expertise in convening difficult multi-agency
  meetings
• Expertise in Chairing sensitive meetings
• Knowledge of multi-agency working
• Knowledge of child protection practice
• Provides experienced minute taker
• Venue Hospital
• Information gathered before meeting

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Summary

• Jan 2006 Sept 2007 total notified deaths 27
• Post death meetings Total 16
• 8 unexpected deaths / cause (4 infections 4 no
  cause)
• 1 adolescent suicide
• 2 asphyxiation ? accidental or deliberate
• 1 asphyxiation accidental
• 1 traumatic delivery
• 3 violence
• No meeting 11
• 6 extreme prematurity
• 4 congenital abnormality
• 1 RTI motorcycle accident

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11
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Post Death Meetings

• Core Group
• LA Child Protection Advisor (Chair) minute
  taker
• Designated Nurse
• Designated Doctor
• Named Nurse hospital trust
• Acute Paediatrician
• Coroner
• LAS manager
• SSD Assessment manager
• Borough Police / CAIT/ MIT

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Post Death Meetings

• Others involved
• GP
• Schools
• YOT
• Disability Teams
• NHS Direct
• Midwifery Manager
• Vol Sector
• Leaving Care Representatives

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Agenda

• Clarify basic details
• Sharing the story
• Discuss significant background information
• Consider needs of family
• Consider safety and protection
• Looking at best support for family
• Consider needs of staff
• Support for staff, risk to staff, press
  involvement
• Identify gaps in information

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Outcome

• NFA
• Consolidate and agree a support plan for family
  (who is best - FLO, HV, SW
• Clarify what other information is needed
• Plans to support staff
• Gather more information and reconvene
• Trigger another process eg Sec 47
• Refer to Serious Case Review Panel

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Challenges

• Geographical
• Children who die somewhere else
• Children who go straight to mortuary
• Children with known life limiting disease who die
  unexpectedly and remain at home (end of life
  strategies)
• Professional
• - Unaware of Chapter 7
• - Misinterpretation of unexplained /unexpected
• - Blame
• - Emotional impact relationship to family
• - Confidentiality

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Parallel process toChild Fatality Review USA ?

• Motivated by a child death we can work together
  as a team with a process that is
• predictable
• supportive
• vigorous.
• Take action that can focus on
• Young children
• and personal failure
• Fits with modern Governance Case Reviewing
  Systems in UK

Dr Michael Durfee MD (ICAN) National Center on
Child Fatality Review
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Child Fatality Review USA
Dr Michael Durfee MD (ICAN) National Center on
Child Fatality Review

• Child Death Review is people who
• Gather to share the pain
• Do something together
• Feel better and
• do it again

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Next Step Overview Panel ??

• Overview Panel to systematically
• review cases
• ? Timing every 3 months
• Use of Cemach forms
• Formulation of meaningful
• data (agree data set)
• Local analysis and recommendations
• Data to London
• for regional analysis
• and recommendations

Local
Regional
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