By: 25 June 2021
Analysis of child deaths in England shows importance of care for premature and young babies

Findings show infant mortality rate (children under one year old) was 3.4 deaths per 1,000 live births

Actions to reduce the number of babies born before 37 weeks’ gestation and improve their outcomes are among the recommendations made by the University of Bristol National Child Mortality Database (NCMD) team, who carried out national analysis of child deaths in England. This is one of the findings, published today [10 June] in NCMD’s second annual report, which aims to learn lessons from all child deaths in order to reduce the number of children who die in the future.

This latest report from Bristol’s NCMD programme, which gathers information on all children who die in England below the age of 18 years, analysed the characteristics of the 3,347 child deaths between 1 April 2019 and 31 March 2020 in England, and found that the majority of children who died (63 per cent) in this period were under one year old. Of these, where gestational age at birth was known, 69 per cent were born preterm (before 37 weeks). In fact, 42 per cent of all child deaths occurred before the children were 28 days old.

For the first time since the start of the national 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. 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. Others include substance and alcohol misuse by a parent or carer, postnatal care and unsafe sleeping arrangements. These factors are important as they enable professionals working with families to identify key areas for improvement, and so this report recommends that actions be put in place at local, regional and national levels to address them.

Overall, there were approximately 28 child deaths for every 100,000 children living in England. A number of other key findings relating to ethnicity, deprivation and location of death (where this data was recorded) are as follows:

  • 62 per cent of children who died were from a White ethnic group, while 19 per cent were from an Asian or Asian British background, 9 per cent were from a Black or Black British background, and 7 per cent 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 per cent of child deaths occurred within a hospital setting.

NCMD now recommends further improvements in the completeness and quality of child death data collected to allow for enhanced future analyses. Karen Luyt, Professor in Neonatal Medicine at the University of Bristol, NCMD programme lead and the report’s senior author, said: “As a society it is incumbent upon us to learn from these tragedies and identify ways in which we can change things to reduce the number of children who die in the future.”
This report goes on to state 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 within to implement changes to address the issues it highlights.

The authors 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. They also wish to express their gratitude to the report’s contributors and to all Child Death Review (CDR) professionals for the data submitted to NCMD as part of the national CDR process.


An online event to disseminate the findings from this report will be held on 22 June 2021, 1-2pm (find out more, including details of how to attend, here).

The National Child Mortality Database Second Annual Report was published on 10 June on the NCMD website. To read the report in full, visit: