Making every contact count: Can healthcare professionals do more to avoid preventable child deaths?

Healthcare professionals (HCPs) have a responsibility and unique opportunities to identify and act on safeguarding concerns. Child Safeguarding Practice Reviews (CSPRs) are produced in the United Kingdom when a child has died or been seriously harmed, and abuse or neglect is suspected or confirmed. To our knowledge there is no recent systematic analysis of CSPRs from an HCP perspective.

To establish if HCPs are acting in an appropriate and safe manner when confronted with cases of potential child abuse and neglect and recommend areas for further improvement.

CSPR abstracts published on a specialist UK database between 2018 and 2021 involving the death of a child.

After applying the exclusion criteria we used stratified random sampling to select one third of eligible reports. Using a systematic framework, common qualitative themes were extracted and analyzed.

42 of 125 eligible CSPRs were analyzed. Child deaths were more common in male children and those aged under one. We identified areas where communication could be further improved including better understanding of the referral process, coordination at discharge, and communication between primary and secondary care. We found that HCPs were not well equipped to identify risk factors for child abuse such as poor parental health and complex family structures.

There is significant scope for improvement in strengthening the knowledge and skill base of HCPs in identifying and acting on signs of child abuse. We propose improvements in terms of staff training, resources and better systems to ensure HCPs respond to safeguarding concerns safely and appropriately.