Abstract
Purpose
The purpose of the study was to determine the proportion of pediatric deaths investigated by HM Coronial autopsy which were potentially preventable deaths due to treatable natural disease, and what implications such findings may have for health policies to reduce their occurrence.
Methods
A retrospective study of 1779 autopsies of individuals between 7 days and 14 years of age requested by HM Coroner, taking place in one specialist pediatric autopsy center, was undertaken. Cases were included if they involved a definite natural disease process in which appropriate recognition and treatment was likely to have affected their outcome. Strict criteria were used and cases were excluded where the individual had any longstanding condition which might have predisposed them to, or altered the recognition of, acute illness, or its response to therapy.
Results
Almost 8 % (134/1779) of the study group were potentially preventable deaths as a result of natural disease, the majority occurring in children younger than 2 years of age. Most individuals reported between 1 and 7 days of symptoms before their death, and the majority had sought medical advice during this period, including from general practitioners within working hours, and hospital emergency departments. Of those who had sought medical attention, around one-third had done so more than once (28 %, 15/53). Sepsis and pneumonia accounted for the majority of deaths (46 and 34 % respectively), with all infections (sepsis, pneumonia and meningitis) accounting for 110/134 (82 %).
Conclusion
Around 10 % of pediatric deaths referred to HM Coroner are potentially preventable, being the result of treatable natural acute illnesses. In many cases medical advice had been sought during the final illness. The results highlight how a review of autopsy data can identify significant findings with the potential to reduce mortality, and the importance of centralized investigation and reporting of pediatric deaths.
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Acknowledgments
ARB is supported by a grant from the Lullaby Trust. NJS is part supported an NIHR Senior Investigator Award, GOSHCC and the NIHR GOSH BRC. This article presents independent research funded by the National Institute for Health Research (NIHR).
Ethical standard
This was a retrospective database study of non-identifiable data. For this type of study formal consent is not required. The study was approved by the local research ethics committee. This study does not contain any studies with human participants or animals performed by any of the authors.
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Bamber, A.R., Mifsud, W., Wolfe, I. et al. Potentially preventable infant and child deaths identified at autopsy; findings and implications. Forensic Sci Med Pathol 11, 358–364 (2015). https://doi.org/10.1007/s12024-015-9681-9
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DOI: https://doi.org/10.1007/s12024-015-9681-9