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New WHO guidelines on paediatric mortality and morbidity auditing
  1. Trevor Duke1,2,
  2. Grace Irimu3,4,
  3. Wilson Were5
  1. 1 Intensive Care Unit and University of Melbourne Department of Paediatrics, Royal Children’s Hospital, Parkville, Victoria, Australia
  2. 2 Child Health, School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, National Capital District, Papua New Guinea
  3. 3 Pediatrics, University of Nairobi, Nairobi, Kenya
  4. 4 Health Services Unit, Centre for Geographic Medicine Research Coast, Nairobi, Kenya
  5. 5 Maternal, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
  1. Correspondence to Professor Trevor Duke, Intensive Care Unit and University of Melbourne Department of Paediatrics, Royal Children’s Hospital, Parkville VIC 3052, Australia; trevor.duke{at}

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It is tragic when a child dies, for the parents, the extended family and the community. It is also sad for the healthcare workers who have been caring for the child.

Although substantial progress has been made in reducing child deaths globally since 1990, many preventable child deaths still occur due to poor quality of care and adverse social and environmental circumstances. Mortality audit and review can help us learn important lessons from child deaths that can guide quality improvement and public policy. It is not new: child death review began in the USA in the 1970s, is a statutory requirement in England and New Zealand and is being implemented at a national level in several other high-income countries, including Australia, Canada, the Netherlands and Wales.1–3 In South Africa, Papua New Guinea and Solomon Islands, and a small number of other low/middle-income countries, mortality auditing has been used to initiate improvements in paediatric hospital care.4–9 The reasons why this has not been done at large scale in the past are several: lack of time, given the high burden of caring for the living; the large number of child deaths in some health facilities and not knowing where to start; fear of blame if audit is conducted in an inappropriate, punitive or insensitive way; difficulty in complying with international coding systems; lack of inclusion of this skill in health training colleges; lack of follow-up of actions; and uncertainty about how to do it. Until now …

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