Scottish Universities Insight Institute : a development from the institute for advanced studies

a development from the institute for advanced studies


Child death review: learning the lessons, differently

Each year in the UK around 260 children die or are seriously harmed and £5 million is spent "learning the lessons". The same "lessons" have been emerging since the first UK child death inquiry in 1945 without noticeable impact on child fatalities. Child death review (CDR) processes in the UK have evolved almost exclusively from social work. We want to think about child death review processes differently, bringing together expertise from the fields of forensic investigation, psychology, education, design, statistics, policing, law, social work and health. With practitioners and key stakeholders from Scottish Government and the Crown Office, we will consider how we can capture, process and disseminate information in the aftermath of child tragedies in cost-effective ways that increase the likelihood of lessons being learned and fewer children dying. We will also draw on the experiences of other UK and international jurisdictions.

The programme explores how the design and operation of CDRs can be optimised to capture the most relevant information, and to maximise learning, for example by looking at how people learn from traumatic events. CDR is an area of policy priority for the Scottish Government and of current interest to UK and US governments. Vincent's research shows other countries also struggle with the CDR process. In an under-researched area, the expertise and innovative approach we are bringing to bear will have national, UK and international impact.

Key objectives

• New areas of inter-diciplinary collaboration
• Maximising the capture of the most significant information from all forms of concurrent investigation of child harm/child fatality to enhance understanding ofwhat turns a safe or risky situation into a dangerous or fatal one;
• Using innovative approaches to knowledge transfer to enhance the dissemination and application of learning from CDRs;
• Strengthening systems for the exchange of information across the forensic/criminal/child protection investigation processes while maintaining evidential integrity;
• Means of evidencing effective and cost-effective prcesses for CDR;
• What Scotland can share from its experiences of CDRs and what it can learn from systems across the UK and beyond.


  • Programme team

Final Report

Download the programme final report and executive summary

External links

Key dates

22 October 2012

14 November 2012

29-30 November 2012