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
