Why Children Die: the report of a pilot confidential enquiry into child death by CEMACH (Confidential Enquiry into Maternal and Child Health)

Abstract

The Confidential Enquiry into Maternal and Child Health (CEMACH) has published a report entitled ‘Why Children Die: A Pilot Study’. The report contains the results of a large confidential enquiry into child death across one-third of England, all of Wales and all of Northern Ireland in 2006. The report contains a quantitative analysis of 957 deaths which shows some regional and ethnic variation in death rates. Also despite high rates of pre-existent and perhaps life-limiting illness/disability, most children die in hospital, with only small numbers in hospices. Child suicide rates were higher than expected and only one-quarter of these cases were known to mental health services. The report also contains a qualitative analysis of a sample of cases ( n = 126) which were subjected review by multidisciplinary panels. Avoidable factors were found in 26% and potentially avoidable in a further 43%. A recurring avoidable factor in relation to healthcare was ‘failed recognition of serious illness’ by healthcare workers not trained in paediatrics or not supervised by trained individuals.