title: Developing effective child death review: a study of 'early starter' child death overview panels in England.
abstract: OBJECTIVE
  This qualitative study of a small number of child death overview panels aimed to observe and describe their experience in implementing new child death review processes, and making prevention recommendations.
  
  
  METHODS
  Nine sites reflecting a geographic and demographic spread were selected from Local Safeguarding Children Boards across England. Data were collected through a combination of questionnaires, interviews, structured observations, and evaluation of documents. Data were subjected to qualitative analysis.
  
  
  RESULTS
  Data analysis revealed a number of themes within two overarching domains: the systems and structures in place to support the process; and the process and function of the panels. The data emphasised the importance of child death review being a multidisciplinary process involving senior professionals; that the process was resource and time intensive; that effective review requires both quantitative and qualitative information, and is best achieved through a structured analytic framework; and that the focus should be on learning lessons, not on trying to apportion blame. In 17 of the 24 cases discussed by the panels, issues were raised that may have indicated preventable factors. A number of examples of recommendations relating to injury prevention were observed including public awareness campaigns, community safety initiatives, training of professionals, development of protocols, and lobbying of politicians.
  
  
  CONCLUSIONS
  The results of this study have helped to inform the subsequent establishment of child death overview panels across England. To operate effectively, panels need a clear remit and purpose, robust structures and processes, and committed personnel. A multi-agency approach contributes to a broader understanding of and response to children's deaths.
authors.affiliation: Health Sciences Research Institute, University of Warwick, Coventry, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Sidebotham
authors.forename: John
authors.initials: J
authors.lastname: Fox
authors.forename: Jan
authors.initials: J
authors.lastname: Horwath
authors.forename: Catherine
authors.initials: C
authors.lastname: Powell
mesh_terms: D000293:Adolescent; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D003625:Data Collection; D003644:Death Certificates; D004739:England / Q000453:epidemiology; D005260:Female; D006287:Health Planning Guidelines; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D036301:Qualitative Research; D011996:Records / Q000592:standards*; D011795:Surveys and Questionnaires; D014947:Wounds and Injuries / Q000401:mortality*; D055815:Young Adult