Developing an understanding of fatal child abuse and neglect : Results from the South African child death review pilot study

Violence against children is a pervasive problem in South Africa (SA). Yet, there is an absence of routine data sources to monitor the prevalence and incidence of child violence, in particular child abuse and neglect. Fatal child abuse is the most severe consequence and forms a proxy measure for the effectiveness of a country’s child protection system. [1] The SA child homicide study estimates a child homicide rate of 5.5/100 000 children <18 years of age[2] – more than double the global child homicide rate. [3] Furthermore, the relationship between child homicide and fatal child abuse was noted, with nearly half (44.6%) of child homicides related to child abuse and neglect. However, child abuse deaths were not always managed within a child protection framework and many of these deaths remain hidden. [4] Underestimating the burden of child maltreatment has been shown in multiple settings, with only a third of these deaths classified as homicide. [5] It is estimated that 13% of all injury deaths in children <15 years old are due to child abuse and neglect. [3] Studies from high-income settings have shown that fatal child abuse is poorly detected in vital statistics, by child protection services, and by the police, resulting in a huge underestimation of fatal child abuse. [5] The poor detection rates of child abuse deaths are primarily owing to difficulties in identifying such deaths, investigating and reporting of such deaths by police to child protection services, and a lack of standard definitions of child maltreatment. [6] Deaths caused by violence or severe physical abuse are more likely recognised as child abuse deaths,[7] while deaths related to neglect/omission of care – including abandonment or those resulting in drowning, poisoning and fire injury – are more likely to remain undetected. [7] Furthermore, deaths in infancy due to asphyxiation from smothering or overlaying (accidental smothering of the child by a larger person lying on them, e.g. in crowded beds) are easily misclassified as sudden infant death syndrome (SIDS), with 10% of SIDS deaths shown to be infanticide. [8] Child death review (CDR) teams have been implemented in high-income countries to address the poor identification of child maltreatment deaths to develop policy and interventions to prevent such deaths. [9] CDR teams aim to review each child death using a public health framework to identify factors to prevent future child deaths. These CDR processes collate comprehensive data for each child death. Viewed as a sentinel event, each suggests potential modifiable factors to inform recommendations for improvement of the health and child protection system. [10] The efficacy of CDR teams is the result of its multidisciplinary nature, consisting of a forensic pathologist, investigating officer, child protection worker (social worker), prosecutor and paediatrician as the core team who meet regularly to share case-specific information on the circumstances surrounding each child death. [11] Over the last three decades, CDR processes have evolved in high-income countries, with variation across countries, but most have adopted a prospective rapid response approach for all unexpected child deaths to understand the clinical causes and contributing factors. [10] Based on gaps identified by the child homicide study and a review of international practices to manage child deaths, a CDR process was identified as best practice for strengthening responses. [12] This article draws on the SA CDR pilot study to explore its use in improved identification of child abuseand neglect-related deaths and the implications for practice.