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691 What can be done to reduce risks of child deaths related to service provision?

Archives of disease in childhood, 2023-07, Vol.108 (Suppl 2), p.A425-A426 [Peer Reviewed Journal]

2023 Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ. ;ISSN: 0003-9888 ;EISSN: 1468-2044 ;DOI: 10.1136/archdischild-2023-rcpch.663

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  • Title:
    691 What can be done to reduce risks of child deaths related to service provision?
  • Author: Kearney, Catherine
  • Subjects: Annual Reports ; Best Practices ; Children ; Communication ; Communication (Thought Transfer) ; Death ; Information sharing ; Neonates ; Pediatrics ; Quality of service ; Reviews ; Supervision ; Training
  • Is Part Of: Archives of disease in childhood, 2023-07, Vol.108 (Suppl 2), p.A425-A426
  • Description: ObjectivesModifiable factors in service provision identified by our Child Death Overview Panel were analysed and themes identified for potential multiagency intervention.MethodsSurvey of reviews of child deaths by Child Death Overview Panel 2016–2018, when the most frequently reported modifiable factor related to service provision. Information from statutory forms submitted to panel, root cause analyses, serious incidents and serious case reviews was analysed identifying the numbers of deaths with service modifiable factors (SMF), themes and category of death.SMF were grouped into -Failure to follow best practice, Record keeping, Lack of escalation medical/safeguarding, Recognition of illness, Training or supervision, Coordination of care/Multiagency working, Communication – family/professionals, Information sharing and Access.ResultsNationally the most frequent modifiable factor related to child deaths is smoking by parents/carers, followed by service quality. In our study, SMFs were the most frequently reported modifiable factor being found in 27/120 reviewed child deaths (2016–18). SMFs related to service quality (42) were most frequent {best practice issues (17), escalation of concerns – medical (10), safeguarding (6), training and supervision (5) and recognition of illness (4)}, followed by communication and information sharing (11). See graph 1 Frequency of Service Modifiable Factor Identified.40% of deaths with a SMF were in the category Perinatal/neonatal deaths (11/27) & 18.5% Infection (5/27)Small numbers limit interpreting trends in SMF over time – none were identified in last year’s annual report.ConclusionsQuality of service and communication and information sharing were our most frequently identified service provision factors. Panel sought robust assurance that providers responded to investigations with comprehensive action plans, monitored through quality teams. Findings from this thematic review were shared with, the then, LSCB and CCG and through local multiagency training.Sadly, these findings are not new1 2 and were noted in the NCMD report June 21;3 the first ever national report collating data on modifiable factors in child deaths. So, what else must be done to reduce the same themes recurring in future child deaths? Learning at individual professional level needs to be supported by systemic changes to address workforce and communication challenges.4 5ReferencesWhy Children die – research and recommendations (2014), posted 1 April 2018, accessed 31.1.23 from https://www.rcpch.ac.uk/resources/why-children-die-research-recommendationsSidebotham P What do serious case reviews achieve? Archives of Disease in Childhood 2012;97:189–192.T. Williams et al., ‘NCMD second annual report. National Child Mortality Database (UK)’, 2021. [Online]. Accessed from: https://www.ncmd.info/wp-content/uploads/2021/06/NCMD_2nd_Annual_Report_June-2021_ web-FINAL.pdf 31.1.23Policy paper: A plan for digital health and social care accessed from https://www.gov.uk/government/publications/a-plan-for-digital-health-and-social-care/a-plan-for-digital-health-and-social-care on 31.01.23The NHS Long Term Plan 7Th January 2019 Accessed from https://www.longtermplan.nhs.uk/publication/nhs-long-term-plan/on 31.1.23Abstract 691 Figure 1Frequency of service modifiable factor identified[Figure omitted. See PDF]
  • Publisher: London: BMJ Publishing Group LTD
  • Language: English
  • Identifier: ISSN: 0003-9888
    EISSN: 1468-2044
    DOI: 10.1136/archdischild-2023-rcpch.663
  • Source: Alma/SFX Local Collection
    ProQuest Central
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