Editorial: Lessons of child deaths unlearned

A year ago, this country was reeling from a series of horrifying child abuse cases. The Minister of Social Services, casting around for more effective child-protection procedures, decided that the collection of data needed to be more efficient and better systems developed. If some in the community wanted a more drastic response, including the mandatory reporting of suspected abuse cases, none doubted that the need for improvements identified by Steve Maharey was real.

Twelve months on there is little evidence of meaningful progress. Indeed, as the Weekend Herald reported, the unexpected death of a child in the community continues to prompt procedures so haphazard as to border on the shameful.

Those who become involved in child deaths, whether police, pathologists or support agencies, seem to operate in an ad hoc manner. Death scene investigations can be incomplete and are often mishandled. Inevitably, that adds to the trauma of a family struggling to cope with the death of a young child from, say, sudden infant death syndrome.

To compound the confusion, there are no consistent dealings between state agencies about child deaths. Neither is there a register where details can be recorded and analysed, and patterns discerned. Lessons go unlearned and lives continue to be lost for want of information and rational procedures.

The degree of dysfunction is alarming in the extreme. As Dr Patrick Kelly of the Starship Hospital child abuse unit says: "Nobody knows how many children and young people are dying and of what they're dying. There's no central system where, if a child or young person dies, a little light goes on to acknowledge that death." So fragmented is the system that it makes a nonsense of the potential benefits of modern communications. And it mocks the efforts of those professionals seeking to impose a sense of order.

Coroners, for example, have campaigned unavailingly for a central database. The fruits of their work - investigations into the causes and circumstances of deaths and the identification of prevention methods - are clearly of huge significance. Yet at present, information from every case referred to a coroner is filed only belatedly, only on paper and only in Wellington. Similarly, suicide numbers collected by Auckland hospital psychiatrists and the review of road deaths conducted by the Land Transport Safety Authority sit in wretched isolation.

If data collection remains lamentable, Mr Maharey has at least tried to bring about a much-needed coordination of the system with the establishment of a Child and Youth Mortality Review Committee. This will examine the death of everyone aged between four weeks and 24 years. It will set up local committees in each health district to gather and analyse data on each death and propose ways to prevent similar deaths. The committees have powers to gather information but have no say in funding.

To operate effectively, they will rely on the cooperation of district health boards. When money is tight, cooperation may need to be enforced by a clear statement of priorities from the Ministry of Health. Even then, the spectre of dysfunction looms. It would be pointless, and wasteful of resources if the committees merely duplicated much of the work of coroners.

Clearly, a comprehensive monitoring system requires the contribution of all agencies in unexpected child deaths. Each of the agencies must follow well-established procedures. It also means setting up a centralised child's death register. Only when the system works logically and efficiently will there be the opportunity to lower the child death rate.

British Columbia offers inspiration. There, a fatality review process under the Children's Commission has helped to reduce the number of deaths from 488 in 1995 to 344 last year. Stunned by the death of a young boy at the hands of his mother, the Canadian province concluded that its child-protection system was hopelessly inadequate. It was not giving the children the priority or the funding they deserved.

New Zealand was shocked into the same conclusion a year ago. Yet even relatively simple prescriptions, such as a register of deaths, have not eventuated. The continuing disorganisation is an indictment of the professionalism of many of those in the health system and the Government's achingly slow response.

As they procrastinate, society's most vulnerable continue to die needlessly.

Feature: Violence at home