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Responding to unexpected infant deaths: experience in one English region
  1. Peter Sidebotham1,
  2. Peter S Blair2,
  3. Carol Evason-Coombe2,
  4. Margaret Edmond2,
  5. Ellen Heckstall-Smith2,
  6. Peter Fleming2
  1. 1University of Warwick, Coventry, UK
  2. 2University of Bristol, Bristol, UK
  1. Correspondence to Dr Peter Sidebotham, Health Sciences Research Institute, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK; p.sidebotham{at}


Aim 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 was carried out 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 h. 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 h 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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  • Funding These studies were supported by grants from the Foundation for the Study of Infant Deaths, Babes in Arms and the Charitable Trusts of University Hospitals Bristol.

  • Competing interests PS is a trustee of the Foundation for the Study of Infant Deaths. PF was a member of the Kennedy Committee that published the intercollegiate document on sudden unexpected death in infancy. Both PF and PS were members of the working group that helped to draft chapter 7 of Working together to safeguard children, the statutory guidance to the Children Act 2004, in which the agreed national approaches to the investigation of unexpected child deaths are set out. None of the other authors have any conflicts of interest. All authors are otherwise independent of the funders.

  • Ethics approval This study was conducted with the approval of the Southwest Multi-Centre Research Ethics Committee and each constituent Local Research Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.