Table 1 Summary of key themes raised in stakeholder interviews
From: How useful are child death reviews: a local area’s perspective
Theme | Typical response |
|---|---|
Information gathering | |
Problems with form B*: gaps in its completion, needs to be simpler | ‘Duplication on Form Bs from different agencies’, ‘only new information should be added by each agency’ |
Timeline for form B completion issued | ‘A national time span for Form B completion should be implemented’ |
Better liaison with the coroner regarding post-mortem information | ‘Representative of coroner should be present at CDOP’ |
Incorporate rapid response, Serious Case Review meetings, Serious Incident (SI), Mortality and Morbidity (MM) hospital findings better into information gathering system | ‘Parallel processes that don’t necessarily converge at CDOP’ |
Better approach to neonatal deaths, especially eliciting additional maternal information | ‘Shift in services to focus more on neonatal and maternal factors’, |
CDOP Meeting | |
Quality assure forms prior to the CDOP meeting | “Improve the quality of information for panel members to review prior to CDOP discussion” |
Information shared with members prior to Panel meeting | ‘Seeing the information beforehand would streamline the CDOP meetings, less questions would be asked’ |
Triage system for some cases that do not need to come to CDOP with particular concern about extremely premature deaths | ‘Separate under 1 years old’ ‘focus on multi-agency cases’, ‘screen out expected deaths’ |
Less delay in completing cases | ‘Delay in CDOP completion of case risks losing the meaning of the case’ |
Terminology used is difficult to interpret | ‘Categorisation as expected and unexpected differs between different professions’, ‘huge discrepancy between what is termed modifiable and non-modifiable’ |
More public health specialist involvement and leadership | ‘Health lead instead of safeguarding lead’ |
Lessons learnt | |
More required to implement lessons learnt | ‘Unclear of how lessons learnt are followed up’, ‘feedback given but not in an auditable fashion’ |
Regular update seminars on lessons learnt | ‘Regular update seminars with designated people from each agency’ |
Better sharing of lessons learnt between CDOPs nationally | ‘Need to pull information together’, ‘feel like we are working in isolation’ |
Process as a whole | |
Death review process is still developmental | ‘A work in progress’ |
Good multi-agency review of child deaths | ‘Good multi-agency review’, ‘the only multi-agency review’, ‘allows access to all information’, ‘encourages to think outside the box’ |
Greater commitment and awareness of Child Death Review Process needed | ‘Feels like an add-on’, ‘often not a high-priority’, ‘more ownership from agencies’ |
Time and resource consuming | ‘Labour intensive’, ‘big time commitment for already busy people’ |