What do serious case reviews achieve?

Although there had been some earlier public inquiries, the inquiry into the death of 7 year old Maria Colwell in 1973[1] was a critical episode in the history of child protection in the UK. It was this inquiry that led to the formalisation of inter-agency child protection procedures, the establishment of Area Child Protection Committees, and the creation of a child protection register. It also sparked off a long line of public inquiries into serious and fatal maltreatment, more recently superseded by statutory Serious Case Reviews (SCRs) carried out by Local Safeguarding Children Boards (LSCBs). The public outcries over the deaths of Victoria Climbié and Peter Connelly highlighted the fact that, in spite of all the time and resource spent on these reviews, the problems of severe child abuse have not gone away. This begs the question of whether we have truly learnt anything from the reviews and whether anything has changed as a result

Investigating sudden unexpected deaths in infancy and childhood and caring for bereaved families : an integrated multiagency approach

The sudden unexpected death of an infant or child is one of the worst events to happen to any family. Bereaved parents expect and should receive appropriate, thorough, and sensitive investigations to identify the medical causes of such deaths. As a result, several parallel needs must be fulfilled. Firstly, the needs of the family must be recognised—including the need for information and support. Further, there is the need to identify any underlying medical causes of death that may have genetic or public health implications; the need for a thorough forensic investigation to exclude unnatural causes of death; and the need to protect siblings and subsequent children. Alongside this, families need to be protected from false or inappropriate accusations. Limitations in the present coronial system have led to delays or failures to detect deaths caused by relatives, carers, or health professionals. Several recent, highly publicised trials have highlighted the possibilities of parents facing such accusations. As a result of this the whole process of death certification has come under intense scrutiny. We review the medical, forensic, and sociological literature on the optimal investigation and care of families after the sudden death of a child. We describe the implementation in the former county of Avon of a structured multiagency approach and the potential benefits for families and professionals

Do we need a new definition for SIDS? : commentary on `Sudden unexpected death in infancy and the dilemma of defining the Sudden Infant Death Syndrome' by Henry Krous

When faced with the multitude of definitions surrounding the infant who dies suddenly and unexpectedly, a paediatrician may feel as bewildered as Lewis Carroll’s Alice before her ovoid friend. In the accompanying discussion paper, Henry Krous, a well respected leader in the field of SIDS research presents a useful discussion of some of the issues raised by different definitions of SIDS

Child death in high-income countries

Although high income countries have made substantial progress towards reducing child mortality over recent decades, rates vary markedly between and within countries, and modifiable factors continue to be identified in many deaths. A series of three articles in The Lancet has described the epidemiology of child mortality and a standardised approach to child death reviews in high income countries. Patterns of child mortality at different ages are delineated into five broad categories: perinatal, congenital, acquired natural, external, and unexplained; while contributory factors are described across four broad domains: factors intrinsic to the child, the physical environment, the social environment, and service delivery. This commentary attempts to draw on the conclusions of these three articles and make practical recommendations on strategies in three key areas with perhaps the greatest potential to further reduce child mortality in high income countries: perinatal conditions, particularly preterm birth; acquired natural conditions, such as sepsis or acute respiratory problems; and external causes, including road traffic fatalities

Maternal filicide in a cohort of English serious case reviews

A national mixed-methods study of English Serious Case Reviews (SCRs) was carried out to better understand the characteristics and circumstances of maternally perpetrated filicides, to compare these with paternally perpetrated cases, and to identify learning points for mental health professionals. Published reports for all SCRs of children in England dying as a result of abuse or neglect from 2011 to 2014 were subject to qualitative analysis using a system of layered reading and inductive thematic analysis, along with descriptive and comparative quantitative analysis. There were 86 deaths directly attributable to child maltreatment within the immediate family. The mother was the suspected perpetrator in 20. Twelve of the mother perpetrators were victims of domestic violence, while 15 of the father perpetrators were known to be perpetrators of domestic violence. Those deaths resulting from impulsive violence or severe, persistent cruelty are almost exclusively perpetrated by males, while those with an apparent intent to kill the child are slightly more likely to be perpetrated by mothers. Four key themes were identified through the qualitative analysis: domestic violence, maternal mental illness, separation and maternal isolation, and the invisibility of the child. These findings highlight the important role of domestic violence and its interaction with maternal mental health. Professionals working with mothers with mental health problems need to adopt a supportive but professionally curious stance, to be alert to signs of escalating stress or worsening mental ill-health, and to provide supportive and accessible structures for at-risk families

Child protection procedures in emergency departments

Background: Emergency departments (EDs) may be the first point at which children who have been subject to abuse or neglect come into contact with professionals who are able to act for their protection. In order to ascertain current procedures for identifying and managing child abuse, we conducted a survey of EDs in England and Northern Ireland. Methods: Questionnaires were sent to the lead professionals in a random sample of 81 EDs in England and 20 in Northern Ireland. Departments were asked to provide copies of their procedures for child protection. These were analysed qualitatively using a structured template. Results: A total of 74 questionnaires were returned. 91.3% of departments had written protocols for child protection. Of these, 27 provided copies of their protocols for analysis. Factors judged to improve the practical usefulness of protocols included: those that were brief; were specific to the department; incorporated both medical and nursing management; included relevant contact details; included a single page flow chart which could be accessed separately. 25/71 (35.2%) departments reported that they used a checklist to highlight concerns. The most common factors on the checklists included an inconsistent history or one which did not match the examination; frequent attendances; delay in presentation; or concerns about the child’s appearance or behaviour, or the parent–child interaction. Conclusions: There is a lack of consistency in the approach to identifying and responding to child abuse in EDs. Drawing on the results of this survey, we are able to suggest good practice guidelines for the management of suspected child abuse in EDs. Minimum standards could improve management and facilitate clinical audit and relevant training

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

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