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Responding to Unexpected Infant Deaths: Experience in One English Region
  1. Peter Sidebotham1,*,
  2. Peter Blair2,
  3. Carol Evason Coombe2,
  4. Margaret Edmond2,
  5. Ellen Heckstall-Smith2,
  6. Peter Fleming2
  1. 1 University of Warwick, United Kingdom;
  2. 2 University of Bristol, United Kingdom
  1. Correspondence to: Peter Sidebotham, Health Sciences Research Institute, University of Warwick, Health Sciences Research Institute, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, United Kingdom; p.sidebotham{at}


New national procedures for responding to the unexpected death of a child in England require a joint agency approach to investigate each death and support the bereaved family. As part of a wider population-based study of sudden unexpected deaths in infancy (SUDI) we evaluated the implementation of this approach.

Methods: A process evaluation using a population-based study of all unexpected deaths from birth to 2 years in the South West of England between January 2003 and December 2006. Local police and health professionals followed a standardised approach to the investigation of each death, supported by the research team set up to facilitate this joint approach as well as collect data for a wider research project.

Results: We were notified of 155/157 SUDI, with a median time to notification of 2 hours. Initial multi-agency discussions took place in 93.5% of cases. A joint home visit by police officers with health professionals was carried out in 117 cases, 75% within 24 hours of the death. Time to notification and interview reduced during the 4 years of the study. Autopsies were conducted on all cases, the median time to autopsy being 3 days. At the conclusion of the investigation, a local multi-agency case discussion was held in 88% of cases. The median time for the whole process (including family support) was 5 months.

Conclusions: This study has demonstrated that with appropriate protocols and support, the joint agency approach to the investigation of unexpected infant deaths can be successfully implemented.

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