The leading causes of child death include respiratory infections, diarrhoeal diseases, measles, malaria, malnutrition and newborn conditions. More than half of child deaths globally are due to conditions that could easily be prevented (via vaccination, appropriate home care, better nutrition) or treated with appropriate access to healthcare. 

Worldwide, major disparities remain in a child’s chance of survival, with low- and middle-income countries disproportionally affected; for example, sub-Saharan Africa has a child mortality rate 15 times higher than that in high-income countries. Sub-Saharan Africa has highest neonatal mortality rate in world at 27 deaths/1000 live births. 

This is a reflection of the uneven coverage of life-saving interventions, essential quality health services and adequate vaccine coverage. More generally, inadequate social and economic development, poverty, overcrowding, poor education, poor nutrition, low levels of breastfeeding, poor air quality, insufficient access to clean water and sanitation are all harmful contributory factors. Quality of life needs to be addressed with children being given a stable environment in which to thrive, including protection from threats and access to educational opportunities. It has been estimated that over 250 million children worldwide (or 43%) are not able to reach their full physical or psychological development. Violence or neglect affects as many as 1 billion of the world’s children. 

Adverse events affect one third of all hospitalized children, with more than 40% of these adverse events being preventable. 

The nature of surgical practice in the paediatric population is distinct in many ways from that in the adult population. Children are not simply small adults. They have unique characteristics, both from a physio-pathological and psycho-behavioural viewpoint, and have specific surgical risks. Age and size impact on vital signs, drug dosing and metabolism, ability to understand and communicate, and type of equipment required. 

Physiological challenges include the transitional circulation of the neonate and their high propensity to suffer from fluid losses and hypothermia during surgery. A child’s airway anatomy is different than that of adults. They have smaller blood volumes, immature immune systems and many other physiologic differences that challenge the surgical team. Use of medical devices and supplies specific for the child are required, with calibres and dosages that vary with the weight and age of the patient. 

Children rely heavily on advocates to speak up for them; parental concerns also need to be acknowledged. Safeguarding issues need to be addressed. All this adds complexity and risks to an already complex situation. 

The delivery of safe children’s surgical care requires development and application of bespoke evidence-based paediatric surgical safety interventions. Specialist paediatric knowledge is needed to reduce missed diagnoses/deterioration. While care is often delivered in generalist settings and adult orientated environments, this is not always appropriate. 

The commonest reported safety incidents for children are different from those for adults. They include errors related to medication, procedures, access, documentation, clinical assessment, consent and devices/technology. Patient safety incidents in neonatology are particularly concerning, accounting for more than 12% of incidents reported for children and young people in the National Reporting and Learning System. The single most frequently reported neonatal safety incident is also medication error. 

In 2007 the Confidential Enquiry into Maternal and Child Health (CEMACH) report ‘Why children die’ found there were preventable factors in 26% of reviewed cases; most were related to poor communication and delayed recognition of the deteriorating child.