Blog: “The value of short lives”

Blog: “The value of short lives”

By NCMD’s Manager, Vicky Sleap.  

42% of child deaths occur in children under 28 days of age; this equates to just over 52 primary school classrooms. 

I was very excited last week about the publication of our second annual report, as it shows the value of strong and ongoing collaboration between Child Death Overview Panel (CDOP)s, Child Death Review (CDR) professionals and the NCMD team. I frequently have the pleasure of speaking to Designated Doctors, CDOP Co-ordinators, JAR nurses and plenty of others about issues of interpretation and guidance. These conversations are reinvigorating for me because they show the dedication and commitment that people have to doing a good job and “getting it right”. Their questions allow me to be involved in intelligent and thought-provoking conversations about issues as diverse as whether a case meets the criteria for a review, the best timing for review of the death (to ensure learning is maximised and families are supported) and how to decide whether a factor is modifiable. All of these discussions have influenced the data that has fed into the annual report and have helped to improve the consistency of reporting and recording across the 58 CDOPs.

The data in the report shows that 42% of child deaths occur in children under 28 days of age. That represents 1,411 children under 28 days of age who died between 1 April 2019 and 31 March 2020. I wanted to try and quantify that in my mind, so I did a bit of Googling and discovered that in 2020, the average UK primary school class size was 27 pupils, so with a very quick bit of maths, I discovered that this equates to enough children to fill just over 52 primary school classrooms. That is a staggering realisation.

I mention this particular fact from the report in my blog, because over the years I have heard people question the value of reviewing neonatal deaths, or what we used to term “expected deaths” i.e. those where the child was known to have a life-limiting condition. This is a perspective I cannot agree with. The strongest and primary motivation to me in reviewing these deaths is to provide answers to the families of those babies about why their child died. Having those answers may help them in the grieving process and give them important information to inform their choices about future pregnancies. But a secondary, and equally important reason, is that if we as a country want to reduce the number of children who die, we cannot expect to do so without reviewing and learning from the biggest single group of deaths. This is not to say that other causes of death eg drowning, road traffic collisions or epilepsy are not equally important to learn from, but thankfully, the numbers of these are much lower – and so our ability to see a big reduction in overall deaths by looking at these is more limited.

Many years ago, I was part of a CDOP panel meeting that was reviewing the death of a baby who died at a few days of age. The panel was privileged to have received some comments from the baby’s mother describing her experience and how she felt about what had happened. She reflected that, although her baby had only lived for a few days, the treatment of his unusual condition had required quick, innovative and “out of the box” thinking from the clinicians involved. She told us in her comments that, despite the fact that the clinical team were experienced and skilled to a high level, her baby had still taught them something new during his short life, and this gave her comfort. I was humbled by her words and remember them now a long time after these events occurred. I embraced the perspective of this mother and I strongly believe that, if she can see what can be learned from her own tragic experience, who are the rest of us to question the value of those deaths when it comes to learning?

I hope you will all read the information in this report and think about how we can learn from the data presented and implement the recommendations. This might only be the first step, but together, I am confident that we can reduce the number of children who die.

NCMD‘s second annual report: Based on data for children who died from 1 April 2019 to 31 March 2020 in England, providing analysis of the 3,347 children who died in that period – is available to read here. 

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NEW: NCMD second annual report published

NEW: NCMD second annual report published

Analysis of child deaths, 2019-20. 

NCMD’s second annual report is based on data for children who died from 1 April 2019 to 31 March 2020 in England, providing analysis of the 3,347 children who died in that period – which equates to approximately 28 child deaths for every 100,000 children living in England.

Commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England, this report offers insights based on the characteristics of the deaths analysed in order to improve outcomes for children in the future. Notably, most deaths occurred before the age of one (63%) and, of these – where gestational age at birth was known – 69% were born preterm (before 37 weeks). In fact, 42% of all children who died were under 28 days old, prompting a recommendation to reduce the number of preterm births and improve outcomes after preterm delivery. In summary, the infant mortality rate (children under one year old) in England over this period was 3.4 deaths per 1,000 live births.

Modifiable factors
For the first time since the start of the child death review process in 2008, factors that are considered to be modifiable in children’s deaths have been analysed on a national scale and included in this report. These factors enable us to identify key areas for improvement. Across all categories of death, the most frequent modifiable factor identified was smoking by a parent or carer. The next most frequently identified factor was gaps in service delivery, while challenges with access to services and poor communication both also feature in the most frequently identified modifiable factors.

Other findings
A number of other key findings relating to ethnicity, deprivation and location of death (where this data was recorded) are as follows:

  • 62% of children who died were from a White ethnic group, while 19% were from an Asian or Asian British background, 9% were from a Black or Black British background, and 7% were from a Mixed ethnic background.
  • There were approximately three times as many deaths of children who were resident in the most deprived neighbourhoods, compared to those from the least deprived neighbourhoods.
  • 78% of child deaths occurred within a hospital setting, while 22% occurred elsewhere.


This report states a clear call to action for all professionals involved in planning or providing services to children to play an active part in reducing the number of children who die, encouraging them to use the data in this report to implement changes to address the issues highlighted by the report.

NCMD also recommends further improvements in the completeness and quality of child death data collected to allow for enhanced future analyses. It is further recommended that actions be put in place at local, regional and national levels to address the modifiable factors identified in this report.

As a society it is incumbent upon us to learn from these tragedies and to identify ways in which we can change things to reduce the number of children who die in the future,” Professor Karen Luyt, NCMD Programme Lead

Finally, we would like to acknowledge that the data presented in this report represent babies, children and young people who have died; and each and every death is a devastating loss. We also wish to express our gratitude to the report’s authors and contributors, and to all Child Death Review (CDR) professionals for the data submitted to NCMD as part of the national CDR process.

To read the report in full, use the link below:

NCMD 2nd_Annual Report June 21

(NOTE: There was an error in Figure 12 in the original publication; this is an updated, corrected version as at 15 June 2021).

Date for your diary: An online dissemination event to share key findings from this report will be held on 22 June 2021 from 1-2pm – to find out more (with details of how to register), click here.

Media enquiries: If you are a member of the public or a journalist requiring further information about this report, please contact the NHS England media team:
– Email:
– Tel: 0113 825 0958.

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‘Super strong’ magnets

‘Super strong’ magnets

Please share this information as widely as possible to help raise awareness of this issue…

The Office for Product Safety and Standards (OPSS), the UK’s national product safety regulator, has issued a Safety Alert to warn of the risk of serious injury and death from swallowing small high-powered magnets

This follows increasing reports of injuries and a small number of deaths after ingestion of magnets, particularly among children and young people. OPSS has identified a particular hazard arising from the use of high-powered magnets in products, where the magnets can be swallowed, such as fridge magnets, earrings, tongue piercings and drink charms.

The public is being asked to take appropriate steps to keep these products away from children as ingestion could result in a serious or fatal injury. Parents or guardians should understand the signs of magnetic ingestion and act quickly to get immediate medical treatment if they believe a magnet has been swallowed.

In addition, OPSS is working with local authority Trading Standards to identify and take appropriate action against any products where magnets that breach the required level of magnetic flux may be ingested by a child.

More information and resources

  • The safety alert issued can be viewed here
  • A news page, which also provides access to some social media messaging, can be found here.
  • A Safety Alert issued by NHS England highlighting the dangers posed by these products and providing guidance on treatment and assessment.
  • Guidance by the Royal College of Emergency Medicine.

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Dissemination event: NCMD second annual report

Dissemination event: NCMD second annual report

Tuesday 22 June 20211-2pm (online)

Hosted by NCMD’s Programme Lead, Professor Karen Luyt, this event will highlight the key findings from our second annual report, which is based on child death data from April 2019 to March 2020. Professor Luyt will also share insights from completed child death reviews during the same period, which will include, for the first time since the start of the child death review process in 2008, national analysis of modifiable factors related to children’s deaths.

How to attend

The event is free to attend, and is open to everyone. It is aimed at Child Death Review (CDR) and child health and social care professionals as well as service planners and commissioners, public health services and policy makers in addition to wider sector professionals working with children and families such as local government, education, and crime. 

To attend this event, you need to register using this zoom link.

After registering, you will receive a confirmation email containing information about joining the event; please ensure that you add this event to your calendar when prompted to do so by zoom

More events
More information – on this and other webinars and online events from NCMD – can be found here.

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