How useful are child death reviews: a local area’s perspective

BACKGROUND: Child 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. FINDINGS: Data 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. CONCLUSIONS: The 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.