Skip to main content
Article thumbnail
Location of Repository

Developing effective child death review : a study of\ud ‘early starter’ child death overview panels in England

By Peter Sidebotham, John Fox, Janet Anne Basarab-Horwath and Catherine Powell


Aim This qualitative study of a small number of child\ud death overview panels aimed to observe and describe\ud their experience in implementing new child death review\ud processes, and making prevention recommendations.\ud Methods Nine sites reflecting a geographic and\ud demographic spread were selected from Local\ud Safeguarding Children Boards across England. Data were\ud collected through a combination of questionnaires,\ud interviews, structured observations, and evaluation of\ud documents. Data were subjected to qualitative analysis.\ud Results Data analysis revealed a number of themes\ud within two overarching domains: the systems and\ud structures in place to support the process; and the\ud process and function of the panels. The data emphasised\ud the importance of child death review being\ud a multidisciplinary process involving senior professionals;\ud that the process was resource and time intensive; that\ud effective review requires both quantitative and\ud qualitative information, and is best achieved through\ud a structured analytic framework; and that the focus\ud should be on learning lessons, not on trying to apportion\ud blame. In 17 of the 24 cases discussed by the panels,\ud issues were raised that may have indicated preventable\ud factors. A number of examples of recommendations\ud relating to injury prevention were observed including\ud public awareness campaigns, community safety\ud initiatives, training of professionals, development of\ud protocols, and lobbying of politicians.\ud Conclusions The results of this study have helped to\ud inform the subsequent establishment of child death\ud overview panels across England. To operate effectively,\ud panels need a clear remit and purpose, robust structures\ud and processes, and committed personnel. A multiagency\ud approach contributes to a broader understanding\ud of and response to children’s deaths

Topics: RJ
Publisher: BMJ Group
Year: 2011
OAI identifier:

Suggested articles


  1. (2005). Abuse Review doi
  2. (2002). Can child deaths be prevented? The Arizona Child Fatality Review Program experience. Pediatrics doi
  3. (1999). Child death reviews: a gold mine for injury prevention and control. Inj Prev doi
  4. (2004). Children Act 2004. London: The Stationery Office,
  5. (1989). Fatalities assessed by the Orange County child death review team, doi
  6. (2010). Injury Prevention doi
  7. (2008). Preventing childhood deaths: an observational study of child death overview panels in England. London: Department for Children, Schools and Families,
  8. Reviewing child deathselearning from the American experience.
  9. (2006). Working Together to Safeguard Children. London: Department for Education and Skills DfES,

To submit an update or takedown request for this paper, please submit an Update/Correction/Removal Request.