Death by Meeting: A Leadership Fable About Solving the Most Painful Problem in Business

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Death by Meeting: A Leadership Fable About Solving the Most Painful Problem in Business

Death by Meeting: A Leadership Fable About Solving the Most Painful Problem in Business

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The ambulance service Emergency Operations Centre will immediately notify the police control room when there is a call to the scene of an unexpected child death. NCMD has received a number of queries from CDR professionals asking for help with running CDRMs. Here we provide guidance on what to think about before, during and after the meeting as well as how to get the most out of the discussion. When a child dies, in any circumstances, it is important for parents and families to understand what has happened and whether there are any lessons to be learned.

Parents should be assured that any information concerning their child's death which they believe might inform the CDOP review would be welcome and can be submitted to the CDOP Management team. These discussions may take the form of telephone discussions. However where the circumstances are complex or there are many professionals involved a further multi-agency meeting(s) may be required. Enable consideration of any child protection risks to siblings/any other children living in the household and to consider the need for child protection procedures and any other action ( Section 47 enquiries)This includes the death of any live-born baby where a death certificate has been issued. In the event that the birth is not attended by a healthcare professional, child death review partners may carry out initial enquiries to determine whether or not the baby was born alive. If these enquiries determine that the baby was born alive the death must be reviewed. Israel’s justice ministry said earlier this month that officials were considering different procedures for putting suspected militants on trial and securing “punishments befitting the severity of the horrors committed”.

Medical examiners should follow national recommendations made within Good Practice Series: National Medical Examiner’s Good Practice Series No 6. – Child Deaths. All children who suffer cardiac and respiratory arrest must be taken to hospital, this will not be a difficult decision on most occasions as the child or baby will be actively resuscitated. However, there are some occasions, although extremely rare, when the decision is made not to resuscitate, historically these cases have been left at home, it is vital that now, even these cases are transported to hospital. This does not mean that resuscitation should be undertaken just to facilitate transport.Clinical judgement should be applied when considering the taking of the Kennedy samples (if there is no apparent cause of death then a full set should be attempted). A discussion should take place between the consultant Paediatrician/Coroner’s Officer and Police Lead Investigator. Any disagreement should be referred to the Coroner. A senior paediatrician, appointed by the CDR partners, who will take a lead in coordinating responses and health input to the child death review process, across a specified locality or region. The purpose of a review and/or analysis is to identify any matters relating to the death, or deaths, that are relevant to the welfare of children in the area or to public health and safety, and to consider whether action should be taken in relation to any matters identified. If child death review partners find action should be taken by a person or organisation, they must inform them. In addition, child death review partners: A National Child Mortality Database (NCMD) formed in April 2019 and collects child mortality data to enable more detailed strategic analysis and interpretation of the data arising from the completed Child Death Review process across England. All CDOP’s are required to submit copies of their analysis and data collected. The NCMD will ensure that child deaths are learned from and this learning is widely shared, both locally and nationally.

A Detective Sergeant, or if unavailable a Detective Constable, from the relevant Safeguarding Investigations Unit should attend in support of the Lead investigator. When Safeguarding Investigations Unit officers are not on duty the Divisional Duty DS or DC should attend the scene but hand over any enquiries to the Safeguarding Investigations Unit at the earliest opportunity. They will: The Qatari prime minister on Sunday said that only minor differences between Hamas and Israel remained to be resolved, but the Israeli prime minister, Benjamin Netanyahu, said no deal had been reached. Where there have been issues with the quality of care provided, healthcare organisations have a duty of candour to explain what has happened, to apologise as appropriate, and to identify what lessons may be learnt to reduce the likelihood of the same incident happening again. This provision should extend beyond the medical sector to any instances of error in the care of the child.For the avoidance of doubt, it does not include stillbirths, late foetal loss, or terminations of pregnancy (of any gestation) carried out within the law. Update the police regarding the movement of the patient if they are not already presentParents have the right to find out what has caused their child to die and getting the investigation underway as soon as possible will give them the best chance of getting that answer. The family should be informed of the further investigations that will need to be carried out, including the post-mortem examination, and how and when they will be informed of the results. NHS serious incident investigations are not conducted to hold organisations or individuals to account. They are designed to generate information that can be used to implement effective and sustainable changes to care provision, to reduce the risks of similar problems occurring in the future. Child death review partners must make arrangements for the analysis of information from all deaths reviewed.



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