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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