The proposed system provides for "local" case reviews, which allows for disciplinary considerations, and a "regional" system that operates alongside it in which standing teams collate anonymous data across numbers of cases. "Local" might be borough- sized localities, and "regional" the equivalent of health regions. The proposal suggests the establishment, under statute, of regional child death review teams, whose members would bring considerable interest and expertise in problems of child abuse. The aims of these teams would be to maintain an overview of all child deaths in the region, to initiate local case review when necessary, to provide expertise to localities, and to accumulate and disseminate knowledge about child abuse. The teams would be notified immediately about each death of, or serious injury to, a child between 0 and 10 years (the years during which the vast majority of fatal abuse occurs). A questionnaire would be circulated to the key members of the professional network involved in the case; their responses would be collated and reviewed by the regional team. This would identify which cases contained clear or suspicious indicators that the child had died from maltreatment, or that neglect or abuse contributed in some way to the fatality. The team would then initiate a local review of the case and provide an independent chair for it. Cases "referred" for local review would enter a system in which named professionals and designated professionals in the health service, as well as uninvolved seniors in other agencies, collate the agency records and prepare a chronology of its staff's work with the family. To capture concerns about the functioning of managers in the agency, or about child protection policies in general, practitioners involved in the case would also be invited to submit their own comments and observations. The Chair of the review team would ensure the inclusion of an accurate genogram and integrate all agency reports into a single chronology. The report would be in a standardized format and identify any concerns about local practice, together with appropriate recommendations. 15 references