Page 3828 - Week 09 - Wednesday, 25 August 2010

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a qualitative information aspect to why a child or young person has died. The aim is to improve our understanding, our responses, our planning and our policy development and ultimately help prevent such deaths in the future.

The current processes in the ACT do not feature all of the components of a child death review committee process. The proposed child death review committee has:

a multidisciplinary panel of experts from a range of areas or backgrounds including legal, medical, child development, child safety and the community;

authority to review all deaths of children and young people that occur in the ACT each year;

the ability to analyse the administrative or clinical issues as well as the wider social or contextual circumstances underlying the death;

a systemic and preventative approach that includes analysis of the factors that contributed to the death and identification of possible strategies or means which might be used to address factors and prevent future deaths;

an independent governance structure with legislated appointment and terms of reference; and

transparency of process and de-identified public reporting of the outcomes of the systemic reviews.

But why is it so critical that we get this data and qualitative narrative? It is important that we understand the context and story to make sure that we can see any real trends and how we respond into the future.

One example from Victoria that may illustrate the need for and benefit of this death review committee occurred when a mother stopped jogging to answer her mobile phone. As she bent down to write her phone number, the pram rolled away and fell into the nearby pond. The mother believed for several hours that her baby had been kidnapped and had no idea that the pram had rolled away.

For statistical purposes, this would have been recorded as a death by drowning. Of course, that was the cause of death. However, the details, the story and the context allow us to understand that this was more than a drowning. The outcome from this particular review was a recommendation that, in the future design and construction of public paths around waterways and water features, the path be constructed to lean away from the water—a very simple and inexpensive strategy. The intention was to ensure that in future any vehicles with wheels, such as prams, would not roll into water; therefore this work was done to prevent future deaths.

Another example is to look at the New South Wales 2008 child death review annual report. In one of its sections, it talked about drowning deaths:

Twenty children died by drowning or submersion in 2008.


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