National review system needed to save lives: experts

Karen Kleiss, Edmonton Journal 


Leading advocates from across Canada say children’s lives could be saved if governments implement a national death review system that is independent, transparent and staffed with experts.

Currently, each province has a separate system for collecting data, which makes it impossible to track trends across the country and undermines attempts to learn from tragic deaths.

Gord Phaneuf, executive director of the Child Welfare League of Canada, said only comprehensive historical analysis can create the foundation for targeted, evidence-based system change that will actually prevent child deaths.

“Any province can lead on that,” Phaneuf said. “What has happened historically, in jurisdiction after jurisdiction, is they deal with the tragedy of the moment. On a personal level we can understand that, but on a governmental level that’s completely inadequate. We need to move past being reactive.”

Photo: Gord Phaneuf, executive director of the Child Welfare League of Canada. Credit: Supplied.

In October, the Canadian Pediatric Society issued a position statement urging governments to establish uniform child death review committees like those in the United States. Dr. Natalie Yanchar authored the statement, which argued that interventions take a long time to yield results, and governments work on four-year election cycles.

“It does take resources, and it’s not immediate satisfaction, so there’s not a lot of political will,” she said. “Hence, you need a little bit of a political stick.”

In the United States, Theresa Covington directs the National Center for Child Death Review.

She said the ideal review system identifies the child’s risk factors, figures out how government systems failed, and offers recommendations to fix the problems. It reviews all child deaths, because children who die from maltreatment or neglect often first appear to have died by accident or from natural causes.

Thoroughly investigating every child death exposes such errors, she said.

And using them to make changes is critical.

“The most important thing is that those recommendations have to go someplace,” Covington said.

“You’re trying to improve systems of care around kids, and you’re trying to prevent more deaths. You’re wasting your time if that’s not what you’re trying to do.”