Plans to review every child death in Scotland

Researchers at Dundee University have trialled the 'Ruby Reviews' system. Picture: Jane Barlow

Around 500 children die each year in Scotland as a result of illness, accidents, suicide or assaults - a higher rate than other European countries such as Sweden.

It is hoped this number could be reduced by carrying out rapid reviews into each child’s death in the hope of learning lessons which would be used to save other lives in future.

Researchers at Dundee University are trialling the process - named Ruby Reviews - for the Scottish Government who have been exploring the feasibility of a review system being put in place across Scotland.

Alyson Leslie, lead researcher on the project, said they had already conducted a number of reviews of deaths in the Tayside region with the hope that even more could be carried out in future.

Short meeting to assess information

The Ruby Review brings together experts and people who knew and cared for the child in one place for a meeting lasting just two to three hours, where hundreds of pieces of information are collected and assessed.

They could involve doctors, paramedics, nurses, scientists and others who can offer information about the circumstances in which the child died to help determine if the death was preventable and make recommendations to improve care and safety of children in future.

They have been named Ruby Reviews in memory of a young girl from Dundee who died as a result of a condition that could be easily treated now.

Ms Leslie said by carrying out the reviews in Scotland, data on 500 deaths would be collected within a year which could provide “invaluable” information for those looking at causes of child deaths.

“There will be so much rich data for people doing research, people trying to find new treatments, people working with other children with those conditions, as well as people working to bring about safer environments for children or better care and welfare,” she said.

Ms Leslie said one example where important lessons could be learned was where a particular product was involved in a child’s death.

“One thing that we know has happened in Scotland a couple of times recently is that children have died as a result of ingesting parts of dishwasher tablets,” she said.

“To a child these are small and colourful, they are naturally attractive. But there are very dangerous chemicals in them.

“It is incidents like that where there are patterns of things that we can begin to pick up.”

She said one review they had carried out involving the death of a child who drowned in the bath had led to them learning a lot about such deaths which she hoped would lead to efforts to prevent the same things happening in future.

“Parents think that they will hear a child in distress and in 98 per cent of cases they do,” Ms Leslie said.

“But the problem is that parents don’t realise that drowning is a silent death and what you actually hear is the absence of sound. It takes you longer to attune to the fact that there is no noise and in those couple of minutes it takes you to realise, the worst could have happened.”

The researcher said they were now looking into introducing an “arm’s reach campaign” to encourage people to stay within arm’s reach of a child in water.

“Our hope is that from awful, heart-breaking tragedies something will be redeemed from every child’s death and we will get some learning that will ultimately help other children,” Ms Leslie added.

Similar systems in USA, Canada

While families do not sit in the reviews, due to the distress this might cause, their views are put across in the meeting and the results fed back to them.

Other countries including the United States, New Zealand and Canada have similar systems to review child deaths which have led to reductions in fatalities.

England also has a system of Child Death Overview Panels, but while this has been seen to work well at a local level it has not been able to gather and use data across the whole country.

Ms Leslie said their reports back to the Scottish Government based on the work carried out so far would “strongly advocate” wider adoption of the reviews which she said were very cost-effective. She said doctors in other parts of Scotland were also showing interest in the process and introducing it in their own areas.