Child Death Reviews London Borough of Croydon

1. Child Death ReviewsLondon Borough of Croydon Briony Ladbury Croydon PCT Dr Shade Alu Croydon PCT DI Tessa Philpott Met Police CAIT Peter Witchlow LB Croydon Children�s Services

2. Setting - Up Priority in Croydon ACPC / CSCB since 2004 � 5 Started to collect data relating to child deaths An attempt to meet 9.11.42 P 186 (Edition 2 of London Child Protection Procedures) �The designated paediatrician should convene within 3 days of the child�s death, a multi-agency discussion or planning meeting�

3. Our Understanding Now 3 distinct areas to develop

4. Post Death Meetings Cases Notified

5. Information Cascade Hospital staff contact Named Nurse CP (Acute) GP Mortuary Liaison HV Social Services Police (if not involved) OOH Child Protection Nurse On Call & EDT Liaison HV Child Health Dept Named Nurse CP (Community) HV � SN other community staff Named Nurse Contacts Designated Nurse Designated Nurse Contacts Designated Doctor SSD Child Protection Lead DI Police CAIT PCT Director LHA via SUI

6. Post Death Meetings All notifications entered onto data base Cascade protocol within 1 working day Decision made re: post death meeting Meeting set up by SSD Child Protection Lead Expertise in convening �difficult� multi-agency meetings Expertise in Chairing sensitive meetings Knowledge of multi-agency working Knowledge of child protection practice Provides experienced minute taker Venue � Hospital Information gathered before meeting

7. Summary Jan 2006 � Sept 2007 total notified deaths 27 Post death meetings Total 16 8 unexpected deaths / cause (4 infections & 4 no cause) 1 adolescent suicide 2 asphyxiation ? accidental or deliberate 1 asphyxiation accidental 1 traumatic delivery 3 violence No meeting 11 6 extreme prematurity 4 congenital abnormality 1 RTI motorcycle accident

8. Post Death Meetings Core Group LA Child Protection Advisor (Chair) + minute taker Designated Nurse Designated Doctor Named Nurse hospital trust Acute Paediatrician Coroner LAS manager SSD Assessment manager Borough Police / CAIT/ MIT

9. Others involved GP Schools YOT Disability Teams NHS Direct Midwifery Manager Vol Sector Leaving Care Representatives Post Death Meetings

10. Agenda Clarify basic details Sharing the story Discuss significant background information Consider needs of family Consider safety and protection Looking at �best� support for family Consider needs of staff Support for staff, risk to staff, press involvement Identify gaps in information

11. Outcome NFA Consolidate and agree a support plan for family (who is best - FLO, HV, SW Clarify what other information is needed Plans to support staff Gather more information and reconvene Trigger another process eg Sec 47 Refer to Serious Case Review Panel

12. Challenges Geographical Children who die somewhere else Children who go straight to mortuary Children with known life limiting disease who die unexpectedly and remain at home (end of life strategies) Professional - Unaware of Chapter 7 - Misinterpretation of unexplained /unexpected - Blame - Emotional impact � relationship to family - Confidentiality

13. Parallel process toChild Fatality Review USA ? Motivated by a child death we can work together as a team with a process that is: predictable; supportive; vigorous. Take action that can focus on Young children; and personal failure Fits with modern Governance & Case Reviewing Systems in UK

14. Child Fatality Review USA Child Death Review is people who� Gather to share the pain Do something together Feel better and do it again

15. Next Step � Overview Panel ?? Overview Panel to systematically review cases ? Timing � every 3 months Use of Cemach forms Formulation of meaningful data (agree data set) Local analysis and recommendations Data to London for regional analysis and recommendations