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
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