Preventing child deaths
Authors: Jane Freemantle, Anne Read
Journal: BMJ (2008)

There is no question that preventing child mortality should be a priority for all, and this is indeed so in the United Kingdom.1 With this objective, the Confidential Enquiry into Maternal and Child Health (CEMACH) has recently conducted a comprehensive review of the deaths of all children aged from 28 days to 17 years and 364 days in Wales, Northern Ireland, and three regions of England (South West, North East, and Midlands).2 This review pre-empts the mandatory review of all child deaths by local safeguarding children boards in England from 1 April 2008.

The aims of the review were to identify and collect core data on all deaths in the five targeted CEMACH regions for the calendar year 2006, to review a subset of these deaths with a focus on identifying avoidable factors, and to consider a national application of the methods. The review undertook a quantitative analysis of a core sample of 957 child deaths. A subset of 126 deaths was selected for closer scrutiny by a series of 41 multidisciplinary panels. These panels were a crucial and critical component of the review process.

The success of the review was dependent on the collaboration of a large number of people and organisations. In particular, the authors should be commended for their collaboration with young people. Increasingly, child health organisations are consulting with young people to provide greater insights into the nature, causes, and potential preventability of such deaths. 

The review identified preventable factors for mortality, but because it was not a case-control study the results cannot necessarily be applied to a wider population. These factors were not detected from the core dataset or from the medical certificates but from the findings of the multidisciplinary panel review. The panel considered relevant information describing circumstances surrounding death. Information from death certificates was inaccurate or insufficient in about a third of the cases reviewed.

The report identified cases of high quality care and cases where, despite the best care and services, the child still died. The most worrying cases were those in which the attending healthcare practitioners did not have the competencies, or systems were not in place, to enable accurate diagnosis or treatment or to facilitate efficient communication. In such circumstances, the inability to identify serious illness in the child and start timely and appropriate treatment were identified as factors in the child’s death. The report also found that particular effort is needed to improve the detection and follow-up of children with mental health problems.

The review recommended the development of a mechanism for the national application and review of the common dataset. It emphasised the importance of disaggregating data so that patterns and trends of mortality in minority and socially or economically deprived populations can be identified. It was acknowledged that systems and expertise for the collection and review of neonatal deaths were already in place and should be used in future planning.

The report found examples of both high quality and substandard primary health care and emphasised the importance of ensuring the maintenance of paediatric skills among general practitioners. Primary prevention, in particular timely and complete immunisation, is vital in preventing child deaths and serious illness.

Mechanisms for reviewing child deaths exist in many jurisdictions throughout the world. These mechanisms vary in structure and function depending on the practices already in place, including existing legislative frameworks, cross jurisdictional relations, and collaborative frameworks. Efficient communication and collaboration between a range of agencies have been widely identified as key factors in effective review of child deaths.

Generally, the literature shows that teams who review child deaths are multidisciplinary and include child protection workers, police, public health workers, medical personnel, mental health personnel, and prosecuting authorities. This shift towards multidisciplinary review teams and local ownership has tended to occur in countries where review processes have previously been more accusatory than investigative.

In Australia, all states and territories except Western Australia have a process for timely review of the deaths of all children who die in their jurisdictions. Many of these processes are supported by legislation to allow pertinent documents to be obtained and to protect the information gathered by the child death reviews. However, mechanisms for determining a score for the “preventability” of a death and avoidable factors are not well developed, although some states and territories are moving to develop such a score. A recent initiative by the commissioner for children in New South Wales has seen the establishment of a National Child Death Review Group, primarily to determine a core dataset for deaths and national consistency in such elements as key definitions.3 Priority has been given to the accurate identification of minority populations within the child death registries, particularly indigenous Australians, to enable differing causes, patterns, and trends in child mortality, systemic problems, and areas of crucial need to be identified.4

In 2005 an important comparative study of case reviews and approaches to child deaths across 16 countries was completed.5 It concluded that comparing countries with different traditions, policies, and processes is difficult, so that models cannot easily be transferred across international borders. An earlier study in the United States of 58 child fatality review teams found that an increasing number of teams collect data and publish reports on the internet, which allows teams to share resources.6

Reviews of child deaths must be rigorous and they should collect timely, standardised, and precise data on all child deaths. Such reviews, combined with appropriate epidemiological research, may help to decrease child mortality—as has been the case with sudden infant death.7 Parents and other carers must also be given feedback and an improved understanding of why their child died.

Future research should incorporate investigations of the medical factors, social factors, environmental conditions, and other circumstances of those who die during childhood compared with those who do not, including primary care and hospital contacts. Coding systems of the cause of death should be clinically relevant and independently validated. Timely and ongoing review will require committed and appropriate funding, leadership, cooperation, effective communication, adequate trained staff in all departments and agencies, and the necessary supporting legal framework.