The report also identified “modifiable factors”, or factors that may have contributed to the deaths of the children, and considered whether risks could have been reduced.
Of the 65 cases reviewed in 2024-25, 86% identified service provision factors such as lack of staffing, bed capacity, equipment and delays in treatment or illness recognition as contributory factors.
This is much higher than the England average for modifiable factors in such cases, which is closer to 40%.
The report does not say those factors directly caused the deaths.
Paul Parsons, head of clinical services at the charity Child Bereavement UK, said the gaps identified in care in Derbyshire could “really disrupt the normal grieving process”, as well as deeply impact children who “don’t have a voice about what they really want”.
“If a child feels safe and secure in an environment that’s familiar to them, then we know that outcomes…are much more positive in such difficult circumstances,” he said.
“The grieving process is difficult enough to navigate anyway without these issues through this report, which has actually shown that the grieving process is contaminated, in a way, by a lack of care.”
Parsons added parents should not have to think about “the practical things that just didn’t happen” in their child’s last moments.
The BBC has contacted NHS Derby and Derbyshire Integrated Care Board for a comment.