Fifth Report of Child Fatality Review Panel released (with photo)

The following is issued on behalf of the Child Fatality Review Panel:
     The Child Fatality Review Panel today (November 23) published its fifth report on the prevention of child death. The report contains 59 recommendations for the prevention of avoidable child fatalities following an analysis of the child death cases in 2016, 2017 and 2018 reported to the Coroner's Court.
     Speaking at a briefing today, the Chairperson of the Review Panel, Dr Eva Dunn, said that children have the right to live in a safe environment and be protected in their vulnerable age. Every child's death is heartbreaking and a tragedy for the family and the community. She expressed the hope that the work of the Review Panel could help prevent avoidable child deaths.
     The review covered the deaths of 259 children aged below 18 who died of natural (159) and non-natural (100) causes. The report revealed that most of the children who had died of non-natural causes lost their lives because of suicide (59), followed by accidents (22), unascertained reasons (eight) and assault (seven). In view of suicide being the second leading cause of death for children over the past 10 years from 2009 to 2018, the Review Panel has completed a thematic review on children and youth suicide deaths.
     Among the 159 natural cause deaths, 12 recommendations were made, which include strengthening multidisciplinary collaboration to engage high-risk pregnant women for timely intervention, reiterating the fatal risk of co-sleeping with babies and strengthening education to parents on safe sleeping arrangements for babies.
     Of the 22 fatal child accident cases, eight children died in traffic accidents and the others died of choking (six), falling from height (six), drowning (one) and accidental hanging (one). Five recommendations were made on the prevention of death resulting from traffic accidents, which comprise reminding parents to hold children's hands tightly when crossing the road or walking past car park exits and children not to cross the road between gaps of parked vehicles and considering legislation for mandatory use of appropriate child car seats in private cars. Furthermore, recommendations relating to home safety were made, including safe use of window grilles with movable padlocks, never leaving children unattended when playing on rooftops and the awareness of choking hazards for babies and young children.
     A total of seven children lost their lives as a result of assault, in which five perpetrators were their parents. Fourteen recommendations were made to prevent such tragedies, which include promoting mental health education, in particular encouraging children who witness their carers having drug-taking behaviour or mental health problems to seek assistance, as well as strengthening inter-departmental collaboration and neighbourhood support for early identification and intervention for at-risk hidden families.
     Among the 59 child or youth suicide cases, 43 persons jumped from height to their death, with the youngest one aged 10. The main reasons for children or youths committing suicide were found to be related to schoolwork problems, family relationship problems, mental problems and relationship problems with boyfriends/girlfriends. Twenty-two recommendations were made in the report targeted at schoolteachers, helping professionals, parents and students for the prevention of child and youth suicide, which include reminding teachers to be alert to students' disclosure of problems through their composition writing or artwork and raising the awareness of teachers on children with aggressive or disruptive behaviours because they may be suffering from psychopathological problems which warrant treatment and professional intervention; strengthening multidisciplinary collaboration in monitoring children with higher suicide risks; strengthening parent education on ways to handle children's addiction to the Internet and online games; and advising students to take all signs of suicidal clues of their schoolmates seriously. Special attention should also be paid to students during various critical periods, such as school resumption after long holidays, release days of school reports, times before and after release of public examination results and promotion to Secondary One.
     Dr Dunn expressed her heartfelt thanks to all of the front-line workers, professionals and managerial personnel of service organisations, professional bodies and government departments who assisted and participated in the review.
     The Assistant Director (Family and Child Welfare) of the Social Welfare Department (SWD), Ms Wendy Chau, expressed her gratitude for the efforts of the Review Panel. She acknowledged the value of the child fatality review mechanism in facilitating improvement and enhancement of the current child protection and child welfare service systems. She said that the Review Panel has passed the recommendations concerned to the relevant bureaux/departments. The SWD and other bureaux/departments have accepted the recommendations and will continue to promote multidisciplinary and cross-sectoral collaboration in protecting children.
     To enhance school social work service, the Government has, starting from the 2018/19 school year, provided public sector primary schools with additional resources to implement the "one school social worker for each school" policy according to the schools' context. To enhance teenagers' mental health and stress resilience, the Government has implemented the measure of "two school social workers for each school" in more than 460 secondary schools in Hong Kong from the 2019/20 school year, and has increased supervisory manpower accordingly to identify and help students with academic, social and emotional problems. In addition, for early identification and provision of assistance to pre-primary children and their families with welfare needs, the Government has also launched a pilot scheme in the 2018/19 school year to provide social work service in phases for pre-primary children and their families in subsidised/aided pre-primary institutions. 
     At the community level, from 2019/20, the 24 Integrated Community Centres for Mental Wellness subvented by the SWD have extended support services to cover secondary school students aged 15 or below (including dropout teenagers), so as to strengthen professional support for them and their families/caregivers, and assist young people with mental health needs to transit into appropriate adult support services.
     The Government attaches great importance to the well-being of children and firmly believes that every child should be protected from harm or abuse. The Government is taking forward legislative work on a mandatory reporting mechanism for child abuse cases, with the target of introducing a Bill into the Legislative Council in the first half of 2023, and at the same time strengthening training for relevant professionals to enhance their capacity for early identification and handling of child abuse cases. The Government will also take forward the recommendations of the Law Reform Commission published in September 2021 on causing or allowing the death of a child. In addition, the SWD will actively promote mutual collaboration and case management among relevant professionals so as to support families in need.
     The SWD has rolled out new TV and radio Announcements in the Public Interest to promote child protection messages and to encourage people facing distress or adversity to seek help. Ms Chau stressed that the SWD will continue to work closely with relevant stakeholders to promote child protection and to provide a comprehensive network of welfare services to strengthen family ties so as to help people better prevent and cope with personal and family problems.
     The full content of the Review Panel's fifth report is available on the SWD homepage ( for public viewing.

Ends/Tuesday, November 23, 2021
Issued at HKT 18:37