Background In order to improve outcomes for acutely unwell children and young people it is essential to learn from those cases in which children deteriorate and die. In our trust there was no universal record of child deaths or deteriorations and no over view of cases to identify learning, either positive or developmental.
Aims The child death and deterioration (CDAD) review group was formed to enable a rapid multi-disciplinary timely review of every child death and unplanned PICU admissions. It allows concerns related to the care or cause of death to be identified, identifies need for more detailed reviews, investigation of adverse events and noting of good practice.
Methods Group includes senior doctors and nursing staff, palliative care and risk team. Weekly meetings review cases from the preceding week. Cases are allocated 15 min and the patient’s team (ideally medical and nursing) presents. Trainees are encouraged to attend. Cases are discussed, actions generated and graded 1–6 according to standard of care given. We also gather parent/ patient feedback regarding unplanned PICU admissions to help provide insight into the perception they have of care provided.
Results/measures Over the first year of CDAD, 38 child deaths and 138 unplanned PICU admissions have been reviewed. Various data including demographics, clinical area admitted from, involvement of outreach and palliative care teams, cause of death/deterioration and clinical grading are available (see figures 1–4). Multiple lessons of positive and negative practices as well as action plans are collated and fed back via care groups QuEST (M and M type) meeting. Favourable event reporting forms are completed for individuals and teams who have delivered excellent care.
Lessons for practice Good discussion between professional groups and different specialities occurs including consideration of number areas of non technical elements. This has identified system, human interaction, equipment, environment and personal factors (including knowledge) that can be improved as well as a number of areas of good practice for spread and adoption.
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