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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.

Abstract

OBJECTIVES

In 2008, new statutory national procedures for responding to unexpected child deaths were introduced throughout England. There has, to date, been no national audit of these procedures.

STUDY DESIGN

Families bereaved by the unexpected death of a child under 4 years of age since 2008 were invited to participate. Factors contributing to the death and investigations after the death were explored. Telephone interviews were conducted, and coroners' documents were obtained. The nature and quality of investigations was compared with the required procedures; information on each case was reviewed by a multiagency panel; and the death was categorised using the Avon clinicopathological classification.

RESULTS

Data were obtained from 91 bereaved families (64 infant deaths and 27 children aged 1-3 years); 85 remained unexplained after postmortem examination. Documentation of multiagency assessments was poorly recorded. Most (88%) families received a home visit from the police, but few (37%) received joint visits by police and healthcare professionals. Postmortem examinations closely followed national guidance; 94% involved paediatric pathologists; 61% of families had a final meeting with a paediatrician to explain the investigation outcome. There was no improvement in frequency of home visits by health professionals or final meetings with paediatricians between 2008-2013 and 2014-2017 and no improvement in parental satisfaction with the process.

CONCLUSIONS

Statutory procedures need to be followed more closely. The implementation of a national child mortality database from 2019 will allow continuing audit of the quality of investigations after unexpected child deaths. An important area amenable to improvement is increased involvement by paediatricians.

Authors+Show Affiliations

Centre for Academic Child Health, University of Bristol, Bristol, UK Peter.Fleming@bristol.ac.uk.Centre for Academic Child Health, University of Bristol, Bristol, UK.Centre for Academic Child Health, University of Bristol, Bristol, UK.Health Sciences Research Institute, University of Warwick, Coventry, UK.Department of Histopathology, Sheffield Childrens Hospital NHS Foundation Trust, Sheffield, UK.Jessop Neonatal Unit, Sheffield Teaching Hospitals, Sheffield, UK.Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.National Congenital Anomaly and Rare Disease Registration Service, Public Health England, Newcastle upon Tyne, UK.Institute of Criminal Justice Studies, University of Portsmouth, Portsmouth, UK.Dave Marshall Consultancy, London, UK.Social Worker (retired), Leeds, UK.Southwest Penninsula Child Death Overview Panel, Plymouth, UK.Centre for Academic Child Health, University of Bristol, Bristol, UK.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

31562184

Citation

Fleming, Peter, et al. "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." Archives of Disease in Childhood, 2019.
Fleming P, Pease A, Ingram J, et al. 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. Arch Dis Child. 2019.
Fleming, P., Pease, A., Ingram, J., Sidebotham, P., Cohen, M. C., Coombs, R. C., ... Blair, P. (2019). 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. Archives of Disease in Childhood, doi:10.1136/archdischild-2019-317420.
Fleming P, et al. 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. Arch Dis Child. 2019 Sep 27; PubMed PMID: 31562184.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - 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. AU - Fleming,Peter, AU - Pease,Anna, AU - Ingram,Jenny, AU - Sidebotham,Peter, AU - Cohen,Marta C, AU - Coombs,Robert C, AU - Ewer,Andrew K, AU - Ward Platt,Martin, AU - Fox,John, AU - Marshall,David, AU - Lewis,Anne, AU - Evason-Coombe,Carol, AU - Blair,Peter, Y1 - 2019/09/27/ PY - 2019/04/15/received PY - 2019/08/26/revised PY - 2019/09/02/accepted PY - 2019/9/29/entrez KW - SIDS KW - bereavement care KW - child deaths KW - unexpected deaths JF - Archives of disease in childhood JO - Arch. Dis. Child. N2 - OBJECTIVES: In 2008, new statutory national procedures for responding to unexpected child deaths were introduced throughout England. There has, to date, been no national audit of these procedures. STUDY DESIGN: Families bereaved by the unexpected death of a child under 4 years of age since 2008 were invited to participate. Factors contributing to the death and investigations after the death were explored. Telephone interviews were conducted, and coroners' documents were obtained. The nature and quality of investigations was compared with the required procedures; information on each case was reviewed by a multiagency panel; and the death was categorised using the Avon clinicopathological classification. RESULTS: Data were obtained from 91 bereaved families (64 infant deaths and 27 children aged 1-3 years); 85 remained unexplained after postmortem examination. Documentation of multiagency assessments was poorly recorded. Most (88%) families received a home visit from the police, but few (37%) received joint visits by police and healthcare professionals. Postmortem examinations closely followed national guidance; 94% involved paediatric pathologists; 61% of families had a final meeting with a paediatrician to explain the investigation outcome. There was no improvement in frequency of home visits by health professionals or final meetings with paediatricians between 2008-2013 and 2014-2017 and no improvement in parental satisfaction with the process. CONCLUSIONS: Statutory procedures need to be followed more closely. The implementation of a national child mortality database from 2019 will allow continuing audit of the quality of investigations after unexpected child deaths. An important area amenable to improvement is increased involvement by paediatricians. SN - 1468-2044 UR - https://www.unboundmedicine.com/medline/citation/31562184/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 L2 - http://adc.bmj.com/cgi/pmidlookup?view=long&pmid=31562184 DB - PRIME DP - Unbound Medicine ER -