Even Reviews Need Reviews: Investigating the presence of Sudden Cardiac Arrest (SCA) in the PA Child Death Review Reports
By Hilary Gray
During my time with Simon’s Fund this summer, I was introduced to the Pennsylvania Child Death Review Program and their work to “promote the safety and well being of children and reduce preventable fatalities.” The program reviews cases of deceased children ages 0-21 on a quarterly basis. Case review occurs within each county of the state, and is performed by a board of professionals, including physicians, coroners, social workers, police chiefs, etc. The data, findings, and proposals of each county’s child death review board are then compiled and published as an annual report. With sudden cardiac arrest and the under coding of SCA in mind, I began to review the annual reports of the review program, with the goal of seeing how SCA is represented. I was startled to find no specific mentioning of sudden cardiac arrest within any of the 5 years of reports I reviewed, and in turn was interested in determining where SCA cases could have been missed. Here is how my investigation played out:
I started my evaluation of the annual reports beginning with the most recently published record from 2012 consisting of the deaths reviewed in 2011, and continued back to the report published in 2009, composed of those deaths reviewed in 2008. From my investigation of these reports of the past five years, I found an alarming amount of potential instances where SCA may have been missed as a means of death and, consequently, many areas where under coding of SCA is likely. (Under coding in this context is when SCA occurs, but is not recorded on the victim’s death certificate.) The review committee organizes the cases into seven categories including natural, accident, suicide, homicide, undetermined, pending, and unknown, based on the victim’s manner of death. I determined the sections of natural, accident, undetermined, and unknown to be those that could potentially include cases where SCA occurred but was not known at the time of death or potentially overlooked during documentation. Within the category of natural death, the four sub-categories of cardiovascular, SIDS, undetermined medical cause, and unknown are of particular interest. The report published in 2009 displays the death distribution within these categories as follows:
|Undetermined medical cause||3||0||0||0||0||0||0||3||0.5%|
After reviewing this data, I found myself questioning whether some of these “natural” deaths could be instances of sudden cardiac arrest. I also questioned why there is no SCA subcategory. Is this because the committee does not find SCA to be the manner of death for any of the cases? Are they included in the section labeled “Cardiovascular” as a possible means of death?
Within the section of the report pertaining to the category of undetermined deaths, the document states, “Based on the CDR team analysis of infants that report an undetermined manner, 28% (5) were reported to have a medical cause of death “like” SIDS or sudden unexpected infant death.” Does a medical cause “like” SIDS include SCA? Could some of these 5 deaths include an infant who suffered from SCA?
To me, these are the cases we need not overlook. In addition, the document goes on to state “12% (6) of those that have an undetermined manner reported an external cause of asphyxia/suffocation.” Could these six cases include a victim of SCA as well?
These are the cases where sudden cardiac arrest may have occurred, and where supplemental review and contact with the families could save the lives of family members. Although such examples are all from the report published in 2009, similar areas of uncertainty occur through all five years of reports I investigated. My review of these reports was not done with the desire to be finicky or hypercritical, but rather with the mindset of preventing future deaths from sudden cardiac arrest. In addition, I have come up with a hypothesis and set of objectives to aid progress towards deeper awareness and consideration of SCA amongst the reviewers of the PA Child Death Review program. My proposal can be seen below:
Hypothesis: Through more careful consideration of the possibility of sudden cardiac arrest as a cause of death, and the subsequent flagging of those cases that present themselves with such an option, undetected heart conditions could be discovered, sudden cardiac arrest could be prevented amongst the family members of victims, and under coding of SCA could be dramatically reduced.
1.Initiate a greater understanding of SCA amongst the members of the review teams.
2.In turn, flag cases where SCA cannot definitely be ruled out as a means of death, and consequently contact the families of these deceased individuals, and encourage them to have their own hearts and those of their family members checked.
3. From those flagged cases, further investigate the possibility of SCA as a means of death, and consequently work to decrease under coding of SCA on death certificates.
1. From thorough examination of the cases already reviewed by the child death review since the year 2000, flag certain cases where the means of death was either inconclusive, uncertain, or vague, and that which overall display SCA as a possibility.
2. Explore the possibility of contacting the families of these flagged cases and encourage them to have their own hearts, and those their family members, checked.
Although there are many potential difficulties and complications in the path to the administration of my proposal, mostly pertaining to confidentiality and privacy, it is my hope that my own investigation will spark similar questions in the minds of others, and thus work to prevent the loss of members of our community.
I encourage you to review the reports for yourself.