Abstract
BackgroundChild Death Overview Panels (CDOP) provide a multidisciplinary and confidential forum to learn from and reduce deaths in those under 18 years. How well they perform and how to improve their effectiveness is a question posed at both local and national levels in England. With this in mind, this study looked at the child death review process in two London boroughs with a joint CDOP.FindingsData on cases reviewed from April 2008 to January 2011 were analysed focusing on cause of death and modifiable factors. Key stakeholders involved in the child death review process were interviewed regarding the effectiveness of the local death review process with responses analysed thematically.105 (50.5%) of all notified deaths were reviewed to completion by CDOP of which 26.7% had modifiable factors. Neonates were the largest group of deaths (42.8%). Stakeholders found reviews time consuming, required significant administration and better integration with related processes e.g. hospital mortality meetings. Too much time was spent analysing cases of limited modifiability such as neonates. Implementation of recommendations needed strengthening and inclusion into the wider health and social care economy including joint strategic needs assessments and commissioning processes. Delayed reporting of information on cases contributed to a backlog.ConclusionsThe current process is bureaucratic, should better address neonatal deaths and needs more focus on implementing recommendations. Solutions include simpler forms, neonates-only subgroups, and linking recommendations to strategic initiatives such as Health and Wellbeing Boards.
Highlights
Child Death Overview Panels (CDOP) provide a multidisciplinary and confidential forum to learn from and reduce deaths in those under 18 years
Child death review activity 208 cases were notified from 1st April 2008 – 31st January 2011, of which 105 (50.5%) were reviewed to completion by CDOP. 61 (29.3%) of the 208 cases notified underwent a rapid response meeting
The main findings can be divided into four distinct sections; i) issues with the CDOP meetings themselves, ii) issues surrounding the implementation of lessons learnt, iii) the logistical obstacles of information gathering and iv) the child death review process as a whole
Summary
There are a few limitations to this study: The findings relate to a CDOP covering two inner-city boroughs with especially diverse and deprived populations and so may not be representative of all CDOPs. In the US, 14% of the states responding to a survey excluded neonates and extreme prematurity from review, but excluding cases was seen as a weakness as coverage of all deaths is necessary for effective prevention [6] Clearer guidance on this tension from national leads would be helpful. The Munro review described the need for a national mechanism for analysing, collating and disseminating local learning [7,10] Whilst this is important, national expertise should be brought to bear on the emerging trends and themes to identify effective interventions, issue guidance and inform future research priorities. Our panel’s experience is that the current process is bureaucratic, time consuming, should better use related case reviews, deal with neonate deaths more effectively and needs more focus on implementing recommendations.
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