Blair, Peter S

Cohen, Martha

Coombs, Robert

Evason-Coombe, C

Ewer, Andrew K.

Fleming, Peter J

Fox, Jon

Ingram, Jenny C

Lewis, Anne

Marshall, David

Pease, Anna S

Sidebotham, Peter

Ward-Platt, M

Objectives In 2008, new statutory national proceduresfor responding to unexpected child deaths wereintroduced throughout England. There has, to date, beenno national audit of these procedures.Study design. Families bereaved by the unexpecteddeath of a child under 4 years of age since 2008 wereinvited to participate. Factors contributing to the deathand investigations after the death were explored.Telephone interviews were conducted, and coroners’documents were obtained. The nature and qualityof investigations was compared with the requiredprocedures; information on each case was reviewed by amultiagency panel; and the death was categorised usingthe Avon clinicopathological classification.Results. Data were obtained from 91 bereaved families(64 infant deaths and 27 children aged 1–3 years); 85remained unexplained after postmortem examination.Documentation of multiagency assessments was poorlyrecorded. Most (88%) families received a home visit fromthe police, but few (37%) received joint visits by policeand healthcare professionals. Postmortem examinationsclosely followed national guidance; 94% involvedpaediatric pathologists; 61% of families had a finalmeeting with a paediatrician to explain the investigationoutcome. There was no improvement in frequency ofhome visits by health professionals or final meetings withpaediatricians between 2008–2013 and 2014–2017 andno improvement in parental satisfaction with the process.Conclusions. Statutory procedures need to be followedmore closely. The implementation of a national childmortality database from 2019 will allow continuing auditof the quality of investigations after unexpected childdeaths. An important area amenable to improvement isincreased involvement by paediatricians

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Quality of investigations into unexpected deaths of infants and young children in England after implementation of national child death review procedures in 2008:a retrospective assessment

https://research-information.bris.ac.uk/ws/files/211365968/Quality_of_investigations_into_unexpected_deaths_of_infants_and_young_children_in_England_ADC_2019.pdf

Quality of investigations into unexpected deaths of infants and young children in England after implementation of national child death review procedures in 2008:a retrospective assessment

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