Aim This qualitative study of a small number of child\uddeath overview panels aimed to observe and describe\udtheir experience in implementing new child death review\udprocesses, and making prevention recommendations.\udMethods Nine sites reflecting a geographic and\uddemographic spread were selected from Local\udSafeguarding Children Boards across England. Data were\udcollected through a combination of questionnaires,\udinterviews, structured observations, and evaluation of\uddocuments. Data were subjected to qualitative analysis.\udResults Data analysis revealed a number of themes\udwithin two overarching domains: the systems and\udstructures in place to support the process; and the\udprocess and function of the panels. The data emphasised\udthe importance of child death review being\uda multidisciplinary process involving senior professionals;\udthat the process was resource and time intensive; that\udeffective review requires both quantitative and\udqualitative information, and is best achieved through\uda structured analytic framework; and that the focus\udshould be on learning lessons, not on trying to apportion\udblame. In 17 of the 24 cases discussed by the panels,\udissues were raised that may have indicated preventable\udfactors. A number of examples of recommendations\udrelating to injury prevention were observed including\udpublic awareness campaigns, community safety\udinitiatives, training of professionals, development of\udprotocols, and lobbying of politicians.\udConclusions The results of this study have helped to\udinform the subsequent establishment of child death\udoverview panels across England. To operate effectively,\udpanels need a clear remit and purpose, robust structures\udand processes, and committed personnel. A multiagency\udapproach contributes to a broader understanding\udof and response to children’s deaths.
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