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The present statutory child death review (CDR) procedures started in April 2008. Five years on, it seems a good moment for reflection: it is instructive to read the online annual reports of different child death overview panels (CDOPs), which give a good flavour of the added value of the procedures, but it seems a shame that these findings are not collated centrally. In writing this I reflect my former role as Designated Doctor for CDR and my current role as Independent Chair of a CDOP. On the one hand these are competing interests, but on the other they have given me an insider view of the CDR process and the many variants of it locally and around the country; and I was one of the paediatricians surveyed in the work that Allen et al report.1
It has always seemed to me that a fundamental principle of any case review, on a child or an adult, is that wherever possible it should be the people looking after the patient who undertake the primary case discussion or review. In relation to a child death, these people might include a medical/nursing team, palliative care personnel, ambulance technicians, police, social worker, general practitioner, school teacher, and possibly others, all depending on the age of the child, the context of the death and the involvement of different agencies. These are the people with the greatest professional stake in the events surrounding the death and the people who, by …
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