Department of Community Paediatrics, South Western Sydney Local Health District, Health Services Building Level 3, Cnr Campbell & Goulburn St., Liverpool, NSW 2170, Australia; School of Women's Children's Health, University of New South Wales, UNSW Sydney, NSW 2052, Australia.
Sydney Local Health District, Croydon Health Centre, 24 Liverpool Road, Croydon, NSW 2132, Australia.
Child Abuse Negl. 2017 Aug;70:283-291. doi: 10.1016/j.chiabu.2017.06.020. Epub 2017 Jul 3.
Child abuse and neglect (CAN) cases presenting to health-services may be complex; when things go seriously wrong such as a child death or near miss, cases are reviewed and health-services and professionals subject to intense scrutiny. While there are a variety of mechanisms to review critical incidents in health-services no formal process for the review of cases where child protection is the primary concern exists in Australia. We aimed to develop a systematic process to review serious events in cases of suspected CAN across two health districts in Sydney, so that shared learnings could fuel system change. Drawing upon mapping, case review, literature findings and using quality improvement methodology, we developed a model named Review of Serious Events (RoSE), in suspected cases of CAN. The RoSE model has the key features of: being child focused; seeking to examine care over a period of time; using child protection staff as lead reviewers; involving health professionals/services in the review who have been involved with the child; and actioning systems change at local levels. The RoSE model was trialled through 2014-2015. Eight cases were reviewed using RoSE; cases were similar to those reviewed prior to having a model. Participant feedback from RoSE group processes was overwhelmingly positive; outputs were transparent and accessible to key stakeholders, there was mixed progress with implementation. The RoSE model is a serious case review process that is strongly child-focused, is both investigative and reflective, led by child protection experts; and can be adapted to other settings and systems.
儿童虐待和忽视 (CAN) 案件向卫生服务机构提出时可能很复杂；当事情严重出错，例如儿童死亡或险些丧命时，案件将被审查，卫生服务机构和专业人员将受到严格审查。虽然有各种机制可以审查卫生服务中的重大事件，但在澳大利亚，没有针对儿童保护是主要关注点的案件审查的正式程序。我们旨在开发一种系统的程序，以审查悉尼两个卫生区疑似 CAN 案件中的严重事件，以便共享学习成果推动系统变革。我们借鉴了绘图、案例审查、文献研究结果，并采用了质量改进方法，为疑似 CAN 案件开发了一个名为严重事件审查 (RoSE) 的模型。RoSE 模型具有以下主要特点：以儿童为中心；试图在一段时间内检查护理；让儿童保护工作人员担任主要审查员；让参与过儿童工作的卫生专业人员/服务参与审查；并在地方层面采取系统变革措施。RoSE 模型于 2014-2015 年进行了试验。使用 RoSE 审查了 8 个案例；这些案例与模型审查前的案例相似。来自 RoSE 小组流程的参与者反馈非常积极；产出对主要利益相关者透明且可访问，实施情况参差不齐。RoSE 模型是一种严重案件审查程序，它非常注重儿童，具有调查和反思性，由儿童保护专家领导；并且可以适应其他环境和系统。
