Sharon Vincent - Preventing Child Deaths: Learning From Review

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PROTECTING CHILDREN AND YOUNG PEOPLE

SERIES EDITORS

ANNE STAFFORD

The University of Edinburgh / NSPCC Centre

for UK-wide Learning in Child Protection

and SHARON VINCENT

Centre for Health and Social Care Improvement, University of Wolverhampton

Preventing Child Deaths: Learning from Review

Sharon Vincent

CONTENTS

ACKNOWLEDGEMENTS

I would like to thank the Leverhulme Trust for providing the funding for me to visit Australia, New Zealand, the United States and Canada. It was an honour to be able to visit these countries and learn about their child death review processes and hear about their efforts to prevent child deaths. Thanks also to the University of Edinburgh, my former employer, for allowing me to take a year out to visit these countries.

Enormous thanks to all the experts within the field, who are too numerous to name in person, who were willing to share their knowledge and devote their time to speak to me. Your input was much appreciated and without your involvement this book would not have been written. I would like to mention in particular Teri Covington, Leah Bromfield, Gythlian Loveday, Rob Ryan and Pam Swinfield. I greatly appreciated your help in identifying useful contacts, and facilitating access to professionals. Thank you for the hospitality you showed to me as a visitor in a strange country. My thanks also to Elly Robinson and colleagues at the Australian Institute of Family Studies, who provided me with a desk with a wonderful view and much needed company while I was in Melbourne.

Finally I would like to thank Kate Alexander and members of our Editorial Advisory Board for kindly reading and commenting on drafts.

LIST OF ABBREVIATIONS

ACC	Accident Compensation Corporation
ACPC	Area Child Protection Committee
BASINET	Baby Abstracting System and Information NETwork
BASPCAN	British Association for the Study and Prevention of Child Abuse and Neglect
BCCS	British Columbia Coroners Service
CA	Childrens Administration
CAN	child abuse and neglect
CAPTA	Child Abuse Prevention and Treatment Act
CCOPMM	Consultative Council on Obstetric and Paediatric Mortality and Morbidity
CDC	Centers for Disease Control and Prevention
CDCR	Child Deaths and Critical Reports
CDCRC	Child Death Case Review Committee
CDNDSC	Child Death, Near Death and Still Birth Commission
CDOP	Child Death Overview Panel
CDPH	California Department of Public Health
CDR	child death review
CDRT	Child Death Review Team
CDRU	Child Death Review Unit
CDSIRC	Child Death and Serious Injury Review Committee
CEMACH	Confidential Enquiry into Maternal and Child Health
CFR	child fatality review
CMCH	Center for Maternal and Child Health
CPAC	Child Protection Accountability Commission
CPS	Child Protection Service
CRU	Case Review Unit
CSSIW	Care and Social Services Inspectorate Wales
CYMRC	Child and Youth Mortality Review Committee
DCSF	Department for Children Schools and Families
DHB	District Health Board
DHS	Department of Human Services
DOCS	Department of Community Services
FCANS	Fatal Child Abuse and Neglect Surveillance
FIMR	Fetal and Infant Mortality Review
FTE	full time equivalent
GCFRP	Georgian Child Fatality Review Panel
ICD	International Classification of Diseases
IRU	Inquiries and Review Unit
LSCB	Local Safeguarding Childrens Board
MCFD	Ministry of Children and Family Development
MCH	Maternal and Child Health
MCHB	Maternal and Child Health Bureau
MoJ	Ministry of Justice
NCCDR	National Center for Child Death Review
NSW	New South Wales
NT	the Northern Territory
OECD	Organisation for Economic Co-operation and Development
Ofsted	Office for Standards in Education, Childrens Services and Skills
ONS	Office of National Statistics
PRUDiC	Procedural Response to Unexpected Deaths in Childhood
QPR	question, persuade, refer
RCPATH	Royal College of Pathologists
RCPCH	Royal College of Paediatrics and Child Health
RRT	rapid response team
SA	South Australia
SCR	Serious Case Review
SID	sudden infant death
SUDI	sudden unexpected deaths in infants
SUID	sudden unexpected infant death
VCDRC	Victorian Child Death Review Committee
WA	Western Australia
WHO	World Health Organization

INTRODUCTION

CHILD DEATH REVIEW

The focus of this book is child death review (CDR) and how the learning from CDR can help us prevent child deaths. Children rarely die, but when they do it is extremely tragic and we have a responsibility to families and communities to find out why they died. CDR, or child fatality review (CFR) as it is sometimes called, enables us to do this.

Evidence suggests that significant proportions of child deaths may be preventable (Pearson, 2008). By examining the circumstances of individual cases where children have died we can define the issues, identify risk and protective factors and develop effective prevention initiatives to help us prevent other deaths in the future (Christian and Sege, 2010).

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