Health Sciences Research Institute, University of Warwick, Coventry, UK.
Inj Prev. 2011 Feb;17 Suppl 1:i55-63. doi: 10.1136/ip.2010.027169.
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.
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.
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.
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.
本项针对少数儿童死亡综述小组的定性研究旨在观察和描述他们在实施新的儿童死亡审查流程以及提出预防建议方面的经验。
从英格兰各地的地方儿童保护委员会中选择了 9 个反映地理和人口分布的地点。通过问卷、访谈、结构化观察以及文件评估等方式收集数据。对数据进行了定性分析。
数据分析揭示了两个总体领域内的多个主题：支持该过程的系统和结构；以及小组的过程和职能。数据强调了儿童死亡审查作为一个多学科过程的重要性，涉及高级专业人员；该过程需要大量资源和时间；有效的审查既需要定量信息，也需要定性信息，最好通过结构化的分析框架来实现；重点应该是吸取教训，而不是试图追究责任。在小组讨论的 24 个案例中的 17 个案例中，提出了可能表明存在可预防因素的问题。观察到了一些与伤害预防相关的建议，包括公众意识运动、社区安全倡议、专业人员培训、制定协议以及游说政治家。
本研究的结果有助于为随后在英格兰各地建立儿童死亡综述小组提供信息。为了有效运作，小组需要明确的职权范围和目的、健全的结构和流程以及有承诺的人员。多机构方法有助于更全面地了解和应对儿童死亡问题。
