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Child death review statutory and operational guidance: maximising learning from child deaths
  1. James Fraser1,
  2. Vicky Sleap2,
  3. Peter Sidebotham3
  1. 1 Department of Paediatric Intensive Care, Bristol Royal Hospital for Children, Bristol, UK
  2. 2 Bristol Medical School: Translational Health Sciences, University of Bristol, Bristol, UK
  3. 3 Health Sciences Research Institute, University of Warwick, Coventry, UK
  1. Correspondence to Dr James Fraser, Paediatric Intensive Care, Bristol Royal Hospital for Children, Bristol BS2 8BJ, UK; bristolfrasers{at}

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A total of 4015 deaths of children aged between 0 and 18 years were registered in England and Wales in 2017.1 Every one of these deaths was a devastating loss that profoundly affected parents as well as siblings, grandparents, extended family and friends. Each death also affected the professionals involved in caring for the child during or at the end of their life. If child mortality rates are regarded as a ‘yardstick’ of a country’s ability to care for the most vulnerable in society, then the UK has fallen far behind its European neighbours.2 3 While the reasons for this are complex, we are not performing well as a nation in addressing known modifiable factors that impact on children’s deaths. This paper summarises the background to child death review in England, the evolving regulatory and legislative landscape and highlights the essential aspects of the new statutory and operational guidance pertinent to practising clinicians.

Background to statutory child death review in the UK

The process of expertly reviewing children’s deaths is grounded in a deep respect for the rights of children and their families. While families experiencing such tragedy should always be met with empathy and compassion, they also want to understand what happened to their child and be assured that any learning arising from their child’s death will help prevent future children’s deaths. The UK has a long tradition in expertly reviewing children deaths. In 2004, Section 11 of the Children Act placed a statutory duty on key people and bodies to make arrangements to safeguard and promote the welfare of children.4 In 2007, Working Together to Safeguard Children outlined the duties of Local Safeguarding Children Boards to identify patterns of death in a community and improve collection of forensic evidence in the small proportion of deaths due to maltreatment. These goals were enabled through setting …

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests JF was a clinical advisor to NHS England for its child death review programme. JF and PS contributed to the statutory and operational guidance.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; externally peer reviewed.