The study found that local child death overview panels (CDOPs), which investigate the circumstances surrounding all child deaths in their area, are hampered in preventing child deaths because there is no straightforward way of spotting national trends.
The report, by the National Perinatal Epidemiology Unit at the University of Oxford, found it took "extensive effort" and "prolonged time" for the panels to identify further deaths from similar causes in other areas and thereby spot potential trends.
This delays any opportunities to see patterns in the causes of deaths, meaning preventative action is not taken.
"As a number of interviewees commented, the absence of national data to enable examination of individual causes of deaths means it is simply not possible to identify the difference between a one-off cause and an emerging trend other than to resort to contacting other CDOP co-ordinators through the informal email network," the report states.
The report found that child death overview panels emailing each other had resulted in the identification of specific trends, such as "nappy sack suffocation", where a baby suffocates on a plastic bag used for the disposal of nappies. Seven-month-old Maison Amison, from Henderson, Staffordshire, died after pulling a plastic bag into his cot in March this year.
However, the time it took to contact other panels or search for news reports of similar cases resulted in delays in spotting trends and taking preventative action.
The report also found examples of local campaign materials to prevent sudden infant deaths, to improve bereavement and palliative care services, and activities around teenage suicides, as examples of learning and sharing that could be further expanded if there was a mechanism for doing so.
The report recommends that a national database be established to enable the “collection, analysis, interpretation and reporting” of the panels' data at a national level.
It goes on to state that the database should be commissioned from a provider that is experienced in national data collection and analysis so it can interpret the findings and to issue appropriate alerts and alarms when necessary as well as producing an annual national report.
The report's findings echo a call by the Foundation for the Study of Infant Deaths, which said in 2011 that a failure to collate and publish national data on the deaths of babies is scuppering the fight against infant mortality.
Emma Rigby, chief executive of the Association for Young Peoples Health (AYPH), said: "AYPH welcomes any initiative which is about sharing data and information to improve outcomes for young people.
"We particularly welcome the focus on suicide prevention.
"We need to make sure that this work links to other work being undertaken to improve integration including initiatives supported by the Children and Young People’s Health Outcomes Forum”
