Derbyshire child death issues

Issues with staffing, capacity, treatment and communication played their part in the deaths of dozens of Derbyshire children and babies.

A report discussed at a Derbyshire County Council meeting this week looked at the deaths of 66 children reviewed in the past year.

Deaths of all children aged from birth to 18 are assessed with the aim of preventing future issues.

The 66 deaths were all reviewed between 2024 and 2025, but some occurred several years before due to delays linked to coroners and court cases, with all lives lost being residents of Derbyshire, but some died elsewhere.

Derbyshire’s child death overview panel found that in 54 of the tragic cases, a factor “that may have contributed to a child’s vulnerability, ill-health or death” was “service provision”.

This includes: Staffing, bed capacity, equipment, initiation of treatment, identification of illness and communication within or between agencies.

Other major contributors were the health and medical conditions of the child and of their “social environment”, such as their family health history, abuse, or alcohol or substance misuse.

Assessing “modifiable factors”, which are ways in which the risk to other children could be reduced through local or national action, the panel found poor communication between agencies in 20 per cent (13 deaths), guidelines available but not followed in 15 per cent (nine deaths) and issues with treatment, including delays, in 14 per cent (nine cases).

The panel found modifiable factors in 86 per cent of cases, up from 66 per cent the year before and far above the national average of 43 per cent.

In Derbyshire, neonatal deaths – babies who died within 27 days of being born – made up half (33) of the deaths reviewed in the past year, higher than the national average of 42 per cent.

Data shown by the panel that Derbyshire has not seen such a high proportion of neonatal deaths since 2019, when they comprised 37 of 70 child deaths.

It also reports that deprivation in Derby led to higher levels of child deaths than should be occurring based on the number of children in the city.

Half of the 66 child deaths – 33 – were Derby residents and half were county area residents, despite Derby making up 28 per cent (around a quarter) of Derbyshire’s total child population.

The meeting was told that one in five of child deaths could be avoided by improving deprived communities.

It also discussed research it had found that Derbyshire had an inconsistent amount of support for children with terminal illnesses who want to die in their own homes, with some unable to do so.

This particularly focuses on a shortfall in 24/7 support for families with children in palliative care – end-of-life care – at home, as advised in national NHS guidance.

The meeting was told that a core reason Derbyshire children were not consistently able to die where they would prefer is due to the low number of terminally ill young people, meaning it has been difficult to justify commissioning such services.

Dr Nic Medd, Derbyshire’s designated doctor for child death, said the NHS providers found it difficult to sign off services which may be barely required for months at a time and then are suddenly in high demand, with some patients needing days or weeks of care and others over a year.

In 60 cases of terminally ill Derbyshire children assessed over the past four years, 16 raised concerns about end-of-life provision.

Dr Medd said on 24/7 home support for terminally-ill children: “At present we can’t say to our families that we can offer that consistently.

“Children in Derby and Derbyshire are not able to access 24/7 palliative care support. It is not available to all our children at present.”

She said many service providers and staff often find ways to provide support through sheer goodwill in their free time after shifts and during on-call shifts, “knowing they won’t be paid for it”, but there is not the specialist support there should be at all times.

Dr Medd said: “There have been situations where that has led to delayed administration of medication that may have alleviated symptoms.”

Nikki Smith, children’s services commissioning officer at the Derbyshire, Nottinghamshire and Lincolnshire Integrated Care Board, said fast-track support packages can be available for terminally ill children, but that medical professionals are not always aware that help is there.

She said that the University Hospitals of Derby and Burton NHS Foundation Trust, which oversees Royal Derby Hospital, provided 24/7 support to three families in the past year, but that further “five or six” families were not given help “due to lack of capacity”.

Dr Medd said there were many challenges facing the service but that none were exclusive to Derbyshire, with the same issues, particularly over commissioning for an inconsistent and unknown demand, being a core national problem.

The Together for Short Lives children’s charity found in late 2024 that Derbyshire is one of at least seven areas in England, but the only one in the East Midlands, that does not provide 24/7 access to palliative care support in the home, despite NHS guidance to do so.

It said in its report, referenced in the meeting, that Nottinghamshire, Leicestershire and Lincolnshire offer partial support, while the only other area in the Midlands not to offer a service is Northamptonshire.

During the meeting, Ms Smith said the integrated care board aimed to provide 24/7 support for terminally ill children at home, in hospital or in hospices across all three counties by 2030.