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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

 People

• 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

 Means

• 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)

 Finance

• Fee for chair and CDR team members

• Reimbursement of travel expenses

 People

• 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

 Means

• 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

 Finance

• 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