Browse/search for people

Publication - Professor Peter Fleming

    Quality of investigations into unexpected deaths of infants and young children in England after implementation of national child death review procedures in 2008

    a retrospective assessment

    Citation

    Fleming, PJ, Pease, AS, Ingram, JC, Sidebotham, P, Cohen, M, Coombs, R, Ewer, AK, Ward-Platt, M, Fox, J, Marshall, D, Lewis, A, Evason-Coombe, C & Blair, PS, 2019, ‘Quality of investigations into unexpected deaths of infants and young children in England after implementation of national child death review procedures in 2008: a retrospective assessment’. Archives of Disease in Childhood.

    Abstract

    Objectives In 2008, new statutory national procedures
    for responding to unexpected child deaths were
    introduced throughout England. There has, to date, been
    no national audit of these procedures.
    Study design. Families bereaved by the unexpected
    death of a child under 4 years of age since 2008 were
    invited to participate. Factors contributing to the death
    and investigations after the death were explored.
    Telephone interviews were conducted, and coroners’
    documents were obtained. The nature and quality
    of investigations was compared with the required
    procedures; information on each case was reviewed by a
    multiagency panel; and the death was categorised using
    the Avon clinicopathological classification.
    Results. Data were obtained from 91 bereaved families
    (64 infant deaths and 27 children aged 1–3 years); 85
    remained unexplained after postmortem examination.
    Documentation of multiagency assessments was poorly
    recorded. Most (88%) families received a home visit from
    the police, but few (37%) received joint visits by police
    and healthcare professionals. Postmortem examinations
    closely followed national guidance; 94% involved
    paediatric pathologists; 61% of families had a final
    meeting with a paediatrician to explain the investigation
    outcome. There was no improvement in frequency of
    home visits by health professionals or final meetings with
    paediatricians between 2008–2013 and 2014–2017 and
    no improvement in parental satisfaction with the process.
    Conclusions. Statutory procedures need to be followed
    more closely. The implementation of a national child
    mortality database from 2019 will allow continuing audit
    of the quality of investigations after unexpected child
    deaths. An important area amenable to improvement is
    increased involvement by paediatricians.

    Full details in the University publications repository