Elsevier

The Lancet

Volume 384, Issue 9946, 6–12 September 2014, Pages 894-903
The Lancet

Series
Learning from child death review in the USA, England, Australia, and New Zealand

https://doi.org/10.1016/S0140-6736(13)61089-2Get rights and content

Summary

Despite pronounced reductions in child mortality in industrialised countries, variations exist within and between countries. Many child deaths are preventable, and much could be done to further reduce mortality. For the family, their community, and professionals caring for them, every child's death is a tragedy. Systematic review of all child deaths is grounded in respect for the rights of children and their families, and aimed towards the prevention of future child deaths. In a Series of three papers, we discuss child death in high-income countries in the context of evolving child death review processes. This paper outlines the background to and development of child death review in the USA, England, Australia, and New Zealand. We consider the purpose, process, and outputs of child death review, and discuss how these factors can contribute to a greater understanding of children's deaths and to knowledge for the prevention of future child deaths.

Introduction

In 2009, 66 000 children younger than 5 years died in high-income countries.1 Although this figure accounts for only a small proportion of the global burden of childhood mortality (8%), up to a quarter of these deaths could be considered preventable (panel 1).3 International data for child mortality are mainly from death certificates, which give little context to the complexity of contributory factors. Many high-income countries are introducing standardised processes for the review of child deaths that regard each death as a sentinel event from which knowledge can be derived. In this review, we consider how the child death review processes can contribute to a greater understanding of how and why children die. With use of the international published work and our specific experience in four high-income countries (the USA, England, Australia, and New Zealand), we show the wide variation in international and national patterns of child death; examine the systems for recording and classification of child deaths and discuss their limitations; review the historical development of formal child death reviews and explain their framework in the USA, England, Australia, and New Zealand. The focus includes England, since child death review processes are established and data available; some death registration data are provided at aggregate UK or England and Wales levels and are reported here as such. We make recommendations for the standardisation of international child death review processes—their purpose, structure, process, and outputs, and how their effectiveness can be measured.

Section snippets

Child deaths: the need for action

In the past century, child mortality in high-income countries has fallen to very low rates. Data from the UK, USA, Australia, and New Zealand show that rates vary by country, sex, and age groups (table 1, appendix).4, 5, 6, 7, 8 Analysis of data from European countries shows variation in child mortality (age 1–14 years) ranging from 13·4 to 14·3 deaths per 100 000 and postneonatal mortality from 0·9 to 1·6 deaths per 1000 livebirths.9 Because of the small numbers in each age group, substantial

Systems to record and classify deaths

Accurate data for child deaths should underpin national and international strategies for child health and wellbeing. Although systems to record and classify child deaths provide national epidemiological data, several limitations affect their value as a public health strategy for the reduction of child mortality. These issues include inaccuracies in the process of death certification, restrictions imposed by reliance on single causes of death and by different systems for grouping cause of death,

Child death review processes

Routine death registration does not capture all factors that might contribute to a child's death. The purposes of a child death review are to systematically gather comprehensive data for child deaths, to identify notable and potentially remediable factors, and to make recommendations for system improvements to prevent future child deaths and improve child health and welfare. To be effective, child death review needs to be multidisciplinary and not limited to health. Although the review is

Effect of child death review

The USA is starting to achieve the potential of a formal child death review process with comprehensive data reporting. In June, 2011, 39 states were enrolled in the US national child death review case reporting system; this number has since increased to 41 states, with a further five scheduled to enrol. The states using the system represent more than 95% of the US population and have more than 95% of all deaths. This internet-based system allows users to enter comprehensive information about

Future challenges

Although many prevention initiatives have been established as a result of child death reviews, whether the review processes themselves have resulted in a reduction in national child death rates has not been assessed. Our search identified only one published study reporting a significant decline in child protection system issues associated with a decline in child deaths after government action on review-finding recommendations.69 To our knowledge, no data have been published for the cost and

Summary

Until the early 20th century, child deaths were not routinely investigated in a separate manner from adult deaths. International child mortality data are limited to information from the death certification process. Detailed comparison of child mortality patterns across high-income countries is a challenge since national departments of statistics present data in many ways—eg, age cohorts and diagnostic details vary in description, and other data such as socioeconomic status and location of death

Search strategy and selection criteria

We searched Medline for papers published in English from Jan 1, 1990, to Dec 5, 2012, using the following terms: (death* review*.mp or fatalit* review*.mp or perinatal mortalit* review*.mp or serious case* review*.mp or critical incident* review*.mp), limited to all child (0–18 years). We reviewed the titles and abstracts of 122 papers. We then retrieved the full text of 31 papers relevant to internally reported processes for child death review. Alongside this process, we searched LexisNexis

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