Government should establish an independent body at national level to oversee a new national learning framework for inquiries into child deaths” Wood Report, 2016

This section explains the history of the National Child Mortality Database programme, starting with the instigation of the Child Death Review (CDR) process in England, 2008-10. It explains the changes that then took place – including the publication of a key report, the Wood Report in 2016, which led to NCMD being established in 2018.

This section also provides links to relevant documents for those who wish to access further relevant resources.

See also, our Frequently Asked Questions


2008: Need for Child Death Review (CDR) process identified

The child death review process in England began on 1 April 2008. This was the result of two high profile miscarriages of justice which led to the convictions, and subsequent exonerations of Angela Cannings and Sally Clark. Professor Peter Fleming was the paediatrician whose work on investigating the deaths of children who die suddenly and unexpectedly (sometimes referred to as “cot death”) played a key role in securing the exonerations of these two mothers who had been wrongly convicted of killing their children.

Professor Fleming identified that in both of these cases, and others, all of the information needed to explain what had happened was obtained within three months of the deaths of their children, but it needed a multi-agency perspective to understand the significance of the information held. Following this it was identified that there was a need to review the deaths of all children to identify what can be learned, to improve the lives of young people and their families and to ensure that no further miscarriages of justice occurred.

2008-10: The beginning of the Child Death Review (CDR) process

When the process was first set up, responsibility for its delivery was given to the Local Safeguarding Children Boards (LSCBs) and the government department who held overall responsibility for the process, then the Department of Children Schools and Families (DCSF) . LSCBs were responsible for improving the overall well-being of children in their local authority area, and each board had a statutory duty to review the deaths of all children normally resident in their area who die before their 18th birthday. At this time, areas with a population of 500,000 or more were required to set up a Child Death Overview Panel (CDOP) and implement a process for the investigation of children who died suddenly and unexpectedly, known as a rapid response. Statutory guidance for the process was set out in a document called Working Together to Safeguard Children and a set of statutory forms were produced to assist LSCBs with data collection and to give CDOPs as much information as possible to review each death.

2010-15: Department for Education takes responsibility for Child Death Reviews

The next milestone for the process came in 2010 when the Department of Children Schools and Families (DCSF) was replaced by the Department for Education (DfE) and the CDR process and Child Death Overview Panels (CDOPs) then became the responsibility of that department. At that time, the statutory forms were also reviewed and updated, and a set of supplementary forms were introduced, designed to ask more detailed questions depending on the cause of death. These were implemented, and local CDOPs began to develop their own amendments to these forms to suit the needs of their individual panels.

2016: Identification of the need for a national database

The process remained largely unchanged until the beginning of the review into the role and function of Local Safeguarding Children Boards (LSCBs) conducted by Alan Wood MP in 2016. Alan Wood’s review identified a number of challenges with the way CDOPs worked and the organisation of the process, and made a number of recommendations. These included: a change in the government department sponsoring the process from the Department for Education to the Department of Health (now Department for Health and Social Care); recognition of the need for child deaths to be reviewed over a population size that allows a sufficient number of deaths to be analysed for patterns, themes and trends; and the implementation of a national database to collate the information gathered by CDOPs.

2017-18: Moving towards Child Death Reviews Statutory and Operational Guidance

Following the publication of Alan Wood’s recommendations, the government held a consultation between October and December 2017 to seek views on revisions to Working Together to Safeguard ChildrenThe consultation asked a number of questions related to the child death review process and the work of CDOPs. The conclusions were then published along with the government’s response to the consultation in February 2018. After that, work began on the revised version of Working Together to Safeguard Children which was published in July 2018. This version made reference to a new document, Child Death Reviews Statutory and Operational Guidance, which was published in October 2018. This document provides a huge level of detail for those commissioning and delivering child death review processes, and aims to reduce some of the variability of practice that had developed between CDOPs over the years to enable a more consistent approach to the review of child deaths. Updates were also made to the statutory forms, new versions of which were published in September 2018.

2016-18: Child Death Review Database Development Project Report and NCMD

Alongside the above activity, the report of the Child Death Review Database Development Project was published in July 2016. This project was commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England and the Health and Social Care division of the Scottish Government. The purpose was to investigate whether and how it might be possible to create a national database of information collected in the course of child death reviews conducted by CDOPs in England and other Child Death Review agencies. The findings of this project demonstrated overwhelming support for the creation of a national child death review database, both from parents and professional stakeholders. In February 2018, the National Child Mortality Database was commissioned to reduce preventable child mortality in England by HQIP on behalf of NHS England. Following a procurement process, a contract was awarded to a collaboration led by the University of Bristol and involving University of Oxford’s National Perinatal Epidemiology Unit, UCL Partners and QES.
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