Public but ineffective: Fatality inquiries into childhood deaths in Alberta

Introduction Child Death Review (CDR) processes are public efforts to review a child’s death to understand how and why children die, to improve child health and to prevent future deaths. In 2013, the Canadian Paediatric Society made specific recommendations to establish structured and comprehensive CDR systems in each province and territory. In Alberta, there is no comprehensive CDR process but there are some components. The most public and probably the most expensive component is the public fatality inquiry. A new notification policy adopted after in June 2017 appears to be of limited value for child death prevention. Methods We examined all Alberta fatality inquiry reports from January 1, 1995 to April 15, 2023 concerning children aged 0-17 years (n=133) to determine whether the fatality inquiry system might be effective in preventing future similar deaths. Results Recommendations made by judges in a fatality inquiry were not always followed by action, and hence inquiry recommendations have been largely ineffective. Fatality inquiry recommendations were sometimes untimely, and therefore had little chance of being effective. There is an increasing trend from 1995 (case 1) to 2023 (case 133) in the time taken to initiate a child fatality inquiry review. Discussion and Conclusion Information and recommendations from fatality inquiries into Alberta childhood deaths tend to be delayed and not followed by action. A comprehensive CDR process is required in Alberta. With system changes, public fatality inquiries could be an effective part of the child death prevention process. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Alberta Children's Hospital Research Institute. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study used only openly available human data published on the Alberta Government Website. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors.