Bradford Child Death Alert learning nuggets

December 2013

Ensuring coordinated support and action for child accident prevention at local level can be a significant challenge.

As well as getting the issue onto the agendas of local leaders, service managers and multi-agency partnerships, it is also vital to equip front-line practitioners with up to date prevention knowledge, evidence information and an awareness of the practical measures which they can take. And all this at a time when budget cuts, staffing reductions and reorganisations can marginalise public health issues such as unintentional childhood injury.

Bradford Child Death Alert

The Bradford Child Death Alert is a low-cost and convenient approach to an urgent local child safety concern. It is also an effective means of stakeholder engagement and workforce development using a simple and easily accessible communication tool.

The Alert format demonstrates local leadership from the Director of Public Health, while the detailed learnings and prevention priorities contained in the message can be adopted and promoted by front-line practitioners in a variety of settings.

Understanding and creating awareness of the risks

In October 2013, the Director of Public Health for the City of Bradford issued a child death and public health alert on child bath drownings. The alert was initiated following a small number of deaths in young babies in the Bradford area in recent years which were as a result of babies or toddlers being left in a bath unattended. Similar cases had been reported around the country, with potentially more ‘near misses’ which were not notified. Bradford’s Injury Prevention Coordinator attended the relevant meetings of the Child Death Overview Panel (CDOP) and drafted the Alert.

The Bradford Child Death Alert on child bath drownings highlighted key facts about:

  • the child safety issue
  • relevant learning from research and evidence including developmental considerations
  • key risk factors – in this case the lack of supervision
  • additional specific concerns, in this case, the danger of relying on bath seats which are intended only as a bathing aid to be used under constant adult supervision
  • action to be taken by ALL health and children’s services staff about reinforcing with parents and carers the need for constant adult supervision of young babies and toddlers in the bath.

This important information was widely disseminated, with the Alert circulated to all relevant professionals and posted on the website of the Bradford Safeguarding Children Board.

Better collaboration and communication for improved children’s outcomes

The use of such a simple but effective means of communication and engagement for child accident prevention reflects the strong emphasis which is increasingly placed on collaboration and coordination to achieve improved outcomes for children and young people.

Key developments include:

Encouraging a more joined-up approach for improved children’s outcomes

As a national priority, the Better health outcomes for children and young people pledge,  aims to encourage health and wellbeing boards, local authorities, health and wider partners to work together to improve children’s health outcomes and to reduce child deaths.

Evidence for local leadership and coordination

NICE Public Health Guidance on preventing unintentional injuries among under 15s highlights the need to incorporate child injury prevention within local plans and strategies. It emphasises the role of  local coordination in achieving these commitments.

Improving the use of evidence from child death reviews

The shared learning, local focus and recommendations for service improvement, together with a better use of child death review data are key to ensuring maximum benefit from the work of child death overview panels (CDOPs).

The role of communication in commissioning a good child health service

The Royal College of General Practitioners (RCGP), in collaboration with the Royal College of Nursing (RCN) and Royal College of Paediatrics and Child Health (RCPCH) endorse the importance of good communication between schools, health visitors and doctors.

"This multi-disciplinary ‘conversation’ needs to be encouraged and supported by commissioners so that it is more structured, resulting in children’s health problems being detected and acted on quickly."


  1. Good and timely communication can help to engage local leaders, service mangers, front-line practitioners and partner organisations for local child accident prevention priorities.
  2. This communication approach is not resource intensive. But it should highlight shared learning and intelligence, key risk factors and the prevention action which needs to be taken.
  3. The information should include links to other relevant resources on the issue which can support local engagement with children, families and the wider community.
  4. Providing ‘the right information, at the right time and in the right way’ has been shown to be important for home safety strategies and ‘brief interventions’. People may be more likely to act on information and advice which comes from trusted and authoritative ‘messengers’, especially those who present information simply and in ways that relate to real-life personal experience and circumstances.

Related links

Updated January 2014