A modifiable (avoidable) factor is a missed opportunity for good care or an example of substandard care which probably lead to the child’s death. No measles immunisation would be a missed opportunity in a 2-year-old child who died of measles, while failure to give adequate rehydration at a clinic would be substandard care in a [...]
If possible, standard national protocols of care should be used. The management which was given can then be compared to the approved management. If a national protocol is not available, the most acceptable method of care should be obtained from a current textbook, journal article or expert on that condition. By asking questions at mortality [...]
For each child, the main cause of death must be identified. This is the most likely factor that lead to the death of the child. Sometimes it is not easy to decide which is the main cause and which are contributing causes. Any other contributing causes should also be recorded. If possible, an ICD 10 [...]
This is one of the most important parts of the mortality meeting. All the possible causes must be considered before agreement is reached on the main cause of death. This is often only agreed upon after some discussion. If the cause of death is not certain, then the probable cause must be used. The cause [...]
Full name, hospital or clinic number, gender (sex), age (date of birth) and date of death. Full clinical history including past history, record of immunisation, review of the growth chart in the Road-to-Health Card, family history and home conditions. Results of a full examination together with an assessment of the growth and nutritional status. Any [...]
A responsible person must be identified to arrange the meeting. This is usually a doctor working in the paediatric service. Regular meetings are held once or twice a month depending on the number of deaths. A suitable time and venue is needed. Often lunch times or late afternoons are best. All staff involved with child [...]
The main aims of a mortality review are to: Obtain data on the number of deaths and calculate the mortality rates. Identify the main cause of death as well as contributing causes. Identify any modifiable factors. Decide whether the child received good management. Allow all the staff involved with child care to contribute to the [...]
This is an in-depth investigation and discussion about each child death. The mortality review is usually done at special mortality meetings. These are regular meeting of staff where every childhood death in that service is reviewed. This includes all children who die in a hospital ward, outpatient or casualty department, and hospital or peripheral clinics. [...]
Modifiable factors can be divided into: Modifiable factors related to the family or caregiver. Examples include not taking children for immunisation, delay in taking an ill child to clinic, poor nutrition, not recognising that a child was ill, neglect and abuse. Modifiable factors associated with the clinical staff. Examples include poor clinical assessment, giving the [...]
