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Child Death Review System

New process will aim to learn lessons from preventable deaths

A multi-agency review to examine the circumstances of every child’s death in Scotland is to become standard practice.

The implementation of a national Child Death Review System will help to identify factors that could reduce preventable childhood deaths and ensure any lessons to be learned are passed to the relevant professionals and services.

The move comes as the Scottish Government accepted the recommendations in a report from the Child Death Review Working Group, published on Thursday.

Currently, while reviews are carried out in certain circumstances, there is no consistent process for reviewing a child’s death across Scotland, and no consistent multiagency groups which review all child deaths. In addition, data collection and the sharing of any lessons learned is limited.

The new system will address this position and is designed to identify any factors that could reduce preventable deaths, i.e. ill health or accident. In criminal or unexplained circumstances, multi-agency reviews already occur and this will continue under the new recommendations.

Cabinet Secretary for Health and Wellbeing, Alex Neil, said: “The death of a child is always a tragedy for the families and it’s only right that the reasons for that death are explored thoroughly to enable us to put in place measures that can help prevent any future tragedies. Setting up this standardised review system will help us to identify what, as a government, we can do to further reduce the rates of child mortality in Scotland and work more closely with families to support them through difficult times.

“We’re keen to ensure, through this process, that bereaved families are at the centre of the review process and that they are given all the information they need in a timely and sensitive manner. Through involving families in each review, they will have the opportunity to feed in their views and will, hopefully, feel reassured that all is being done to help prevent the likelihood of similar deaths happening again.”

In Scotland, between 350 and 450 deaths in those aged under 18 occur each year, with the most deaths occurring in children aged under 1. Of the other age-groups, 15-18 has the largest number of deaths: each of the 1-4, 5-9 and 10-14 age-groups has relatively few deaths. The causes of death in the 0-1 age range bracket are usually related to prematurity and birth defects. Causes in the 15-18 age range relate largely to trauma including road traffic accidents and teenage suicide.

The new Child Death Review System in Scotland would collect and distribute local and national data among key partners to identify common themes on avoidable deaths and spot any emerging trends.

A strategic group will oversee this work and make appropriate recommendations to policy makers in public health. In addition it will also establish standards of communication with bereaved families to ensure they are always dealt with in an appropriate and sensitive way by police and health workers.

A steering group will now be set up to develop this Scottish review system, which will be informed by a pilot programme currently being undertaken in Tayside.

Notes To Editors


Compared with all other European countries, the UK is in the bottom third for infant mortality rates [UNICEF: “Child Wellbeing in rich countries” (2013)]

The Child Death Review Working Group was established to explore Scotland’s current practice in the review of child deaths and look at the possibility of introducing a national review system in order to identify preventable causes of death. It included representatives from the Scottish Government, Health Boards, Royal College of Paediatrics & Child Health, Scottish Cot Death Trust, Police Scotland, University of Dundee, Crown Office and Procurator Fiscal.

The Working Group’s report, ‘Child Death Review Report’ is available on the Scottish Government website

Tayside pilot:

The Fatality Investigation and Review Studies team (FIRST) at University of Dundee, in collaboration with the School of Medicine and with the support of NHS Tayside, are piloting a model of child fatality review in Tayside between January and April 2014. The project is jointly funded by the Scottish Government and the University of Dundee Alumni Fund.

A short multi-agency meeting review each death and determines whether it was preventable and what recommendations, if any, can be made to reduce the likelihood of similar deaths. A family liaison worker is also employed to support the recently bereaved families who are contributing to the pilot, ensuring their views and recommendations are being fed back into the review process.

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