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Table 2 Overview of the strengths, weaknesses, opportunities and threats identified in the child death review pilot study

From: Implementation of Child Death Review in the Netherlands: results of a pilot study

Strengths Weaknesses
• CDR coordinator
- contributed to the inclusion of cases
• Chair
- forensic and pediatric expertise
- supported in writing the chronological report
• Team
- multidisciplinary approach
- made proposals and recommendations directed at the intake and analysis of cases
- reached consensus to refine the CDR procedure
• Materials to inform parents and professionals (leaflet for parents, consent form, SERRAFIM website)
• Materials to review a case (DVD ‘Why Jason died’, CDR protocol, confidentiality agreement, document with rules for an efficient meeting, intake and analysis form, recording equipment)
• Fee for chair and CDR team members
• Reimbursement of travel expenses
• CDR coordinator
- could not complete the process to get parental consent in 2 cases in time
- failed once to send the documents for the CDR meeting in time
- has insufficient expertise to select relevant information from the medical record of the deceased child
• Chair and CDR team members
- voluntariness of participation
• CDR team
- limited experience
• Lack of essential information from professionals and parents
• Illogical ranking of items on the intake and analysis forms
• Lack of a clear description how to define the primary and secondary cause of death and the way a death should be classified
• Insufficient financial resources for the CDR coordinator
Opportunities Threats
 Political factors
• Added value to the legally prescribed NODO-procedure
• National attention of the topic ‘child death’
• Providing a source of information for professionals, parents and others
 Social factors
• The objectives of the CDR promoted participation
 Environmental factors
• Collaboration with the National Cot Death Study Group
• Reduction of the effort for parents in providing information
• Highlighting positive experiences
• Presenting at conferences or meetings and publishing in national magazines
• Making use of experiences with conducting reviews nationally and in the UK
 Legal factors
• Cooperation of the Public Prosecutor
• Signed consent form to obtain information
 Political factors
• The influence of the NODO-procedure on the inclusion of cases
 Social factors
• Personal reasons of parents and professionals for not participating
 Environmental factors
• Influence of the Dutch Healthcare Authority on the participation of health care professionals in the CDR team
 Legal factors
• Lack of statutory basis