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A Service evaluation of a hospital child death review process to elucidate understanding of contributory factors to child mortality and inform practice in the English National Health Service
  1. Daniel S Magnus1,
  2. Margrid B Schindler2,
  3. Robin D Marlow3,
  4. James I Fraser4
  1. 1 Department of Emergency Medicine, Bristol Royal Hospital for Children, Bristol, UK
  2. 2 Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, Bristol, UK
  3. 3 Population Health Sciences Department, Bristol Children’s Hospital, Bristol, UK
  4. 4 Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, Bristol, UK
  1. Correspondence to Dr James I Fraser; james.fraser{at}


Objective To describe a novel approach to hospital mortality meetings to elucidate understanding of contributory factors to child death and inform practice in the National Health Service.

Design All child deaths were separately reviewed at a meeting attended by professionals across the healthcare pathway, and an assessment was made of contributory factors to death across domains intrinsic to the child, family and environment, parenting capacity and service delivery. Data were analysed from a centrally held database of records.

Setting All child deaths in a tertiary children’s hospital between 1 April 2010 and 1 April 2013.

Main outcome measures Descriptive data summarising contributory factors to child deaths.

Results 95 deaths were reviewed. In 85% cases, factors intrinsic to the child provided complete explanation for death. In 11% cases, factors in the family and environment and, in 5% cases, factors in parenting capacity, contributed to patient vulnerability. In 33% cases, factors in service provision contributed to patient vulnerability and in two patients provided complete explanation for death. 26% deaths were classified as potentially preventable and in those cases factors in service provision were more commonly identified than factors across other domains (OR: 4.89; 95% CI 1.26 to 18.9).

Conclusions Hospital child death review meetings attended by professionals involved in patient management across the healthcare pathway inform understanding of events leading to a child’s death. Using a bioecological approach to scrutinise contributory factors the multidisciplinary team concluded most deaths occurred as a consequence of underlying illness. Although factors relating to service provision were commonly identified, they rarely provided a complete explanation for death. Efforts to reduce child mortality should be driven by an understanding of modifiable risk factors. Systematic data collection arising from a standardised approach to hospital reviews should be the basis for national mortality review processes and database development.

  • paediatrics
  • health policy
  • clinical governance
  • mortality

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  • Contributors DSM and JIF conceived and designed the project. DSM acquired and analysed the data. DSM drafted the written work with considerable input from JIF and MBS who revised it critically for important intellectual content and collaborated on final approval of the published version. RDM provided additional statistical analysis and comments on the final manuscript.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests During the period of study, and at the time of original writing and submission of the manuscript there were no competing interests. JIF has a long-standing interest in the causes of child mortality and subsequently has been engaged by NHS England to advise on national child death review processes.

  • Patient consent Not required.

  • Ethics approval Anonymised data in this study is routinely collected on all deceased children as per UK statutory regulation (working together to safeguard children, 2013). Permission for the use of this data for research purposes was gained from the regional child death overview panel office.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All original data from the study is available to be shared. DM, as the primary investigator, holds all original data.