1775 Development of a national hub for reviewing and learning from the deaths of children and young people in Scotland

• Published in: Archives of disease in childhood Vol. 106; no. Suppl 1; pp. A484 - A485
• Main Authors: Feilden, Nanisa, Rennie, Alison, Sands, Jill, McGeachie, Caroline, Robertson, Sharon
• Format: Journal Article
• Language: English
• Published: London BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health 01.10.2021; BMJ Publishing Group LTD
• Subjects: Abstracts; Children; Children & youth; Death; Decision making; Families & family life; Learning; Mortality; Pediatrics; Preventable deaths; Quality control; Reflective Teaching; Young Adults; United Kingdom > UK; Scotland
• ISSN: 0003-9888; 1468-2044
• DOI: 10.1136/archdischild-2021-rcpch.842

BackgroundScotland has a higher mortality rate for under 18s than any other Western European country. Of the 300 children and young people who die annually, approximately a quarter could be prevented. There is currently no national system to support review or to share national learning, and not all deaths are reviewed. The quality of reviews varies across services and Scotland.Healthcare Improvement Scotland and the Care Inspectorate co-host the National Hub for Reviewing and Learning from the Deaths of Children and Young People.ObjectivesThe National Hub aims to ensure that the death of every child in Scotland is subject to a quality review by:developing a methodology and documentation to ensure all deaths are reviewed through a high quality and consistent processimproving the quality and consistency of existing reviewsimproving the experiences of and engagement with families and carers, andchannelling learning from current review processes across Scotland that could direct action to help reduce preventable deaths.This programme reflects the commitment to fostering a learning system that increases safety and quality improvement amongst services by:supporting individuals to learn through its culture and networksensuring everyone is informed by evaluation and reflective practiceenabling people to assess what is and is not working through the use of qualitative and quantitative data, stories and insightsdeveloping processes to aid decision-making and turn knowledge into actionbuilding systems to identify ’bright spots’ and generalisable learning, andlinking with rUK systems to allow a four nations approach to child death reviews.MethodsWe have worked collaboratively with stakeholders to support implementation of a national child death review process, which will launch during 2021. This includes:establishing an Expert Advisory Group to provide an advisory role through expert (including clinical) inputdeveloping national guidance that sets out the process for NHS boards and local authorities to follow when responding to, and reviewing, the death of a child or young persondeveloping a core review data set and online portal for collating data, andgathering views from family members and carers who have been involved in a review process. Reviews will be conducted into the deaths of all live born children up to the date of their 18th birthday, or 26th birthday for care leavers who are in receipt of aftercare or continuing care at the time of their deathResultsThe national child death review process will be fully implemented by 1 October 2021.Following implementation, the National Hub will collate and disseminate learning from reviews with the aims of changing future professional clinical practice, informing policy change and reducing avoidable deaths in Scotland.ConclusionsFor the first time in Scotland, national data will be collected on the deaths of all children and young people. Working with NHS boards and local authorities, the ambition is to inform the redesign of pathways and services to ultimately reduce avoidable deaths, and where that is not possible, to improve the experiences of children, young people and their families