Common Factors in Serious Case Reviews of Child Maltreatment where there is a Medical Cause of Death: Qualitative Thematic Analysis
Authors: Garstang Joanna , Eatwell Daisy , Sidebotham Peter , Taylor Julie 
Published: January 2021

AbstractAimTo identify common factors in Serious Case Reviews (SCRs) where a child has died of a medical cause. Design: Qualitative thematic analysis.BackgroundSCRs take place when neglect or abuse results in children dying or being seriously harmed. Known key factors within SCRs include parental substance misuse, mental health problems, and domestic abuse. To date there has been no investigation of children who die of a medical cause where there are concerns about child maltreatment.Data sourcesA list of SCRs relating to deaths through medical causes was provided from previous coded studies and accessed from the NSPCC National Case Review Repository. Twenty-three SCRs with a medical cause of death from 1stApril 2009-31stMarch 2017 were sourced.ResultsTwenty children died of an acute condition and 12 of a chronic condition; 20 of the deaths were unexpected and maltreatment contributed to the deaths of 18 children. Most children were either under one or over 16 at time of death. Many parents were caring for a child with additional vulnerabilities including behavioural issues (6/23), learning difficulties (6/23), mental health issues (5/23) or a chronic medical condition (12/23). Common parental experiences included: domestic violence/abuse (13/23), drug/alcohol misuse (10/23), mental ill health or struggling to cope (7/23), criminal history (11/23), and caring for another vulnerable individual (8/23). Most children lived in a chaotic household characterised by missed medical appointments (18/23), poor school attendance (11/23), poor physical home environment (7/23) and disguised compliance (12/23). All 23 SCRs reported elements of abusive or neglectful parenting. In most there was evidence of cumulative harm, where multiple factors contributed to their premature death. At the time of death 11 children were receiving social care support.ConclusionWhile the underlying medical cause of the child’s death was often incurable, the maltreatment that often exacerbated the medical issue could have been prevented.Article Summary. Strengths and weaknesses of the studyNo other study has analysed SCRs in which children have died of medical causes.The most complete dataset possible was used to conduct the robust analysis: SCRs were sourced from the complete list from the Department for Education used for previous national analyses of SCRs.Randomly selected SCRs were re-coded by two further researchers to check for any discrepancies in coding, increasing the reliability of results.Not all child deaths lead to SCR, even when there are concerns about maltreatment; local areas may differ on their threshold of suspicion; content within SCRs is often variable and inconsistent; so there may be deaths relevant to this study which were not included.We only investigated those cases in which a child died, focusing therefore on the worst cases and perhaps missing incidents in which a child had a medical condition and experienced maltreatment but did not die.