Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Caring for bereaved families
- Richard N Wood (11 February 2004)
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Need for expert laboratory investigation of sudden unexpected deaths in infancy
- Natasha S. Crowcroft, Robert George and Cyprian Okoro (27 February 2004)
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Sudden unexpected infant death - implementing guidelines
- Anne Livesey, Detective Sergeant Edmund Hick, Sussex Police (29 March 2004)
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Paediatric Pathologists: If impartiality is unattainable, integrity must be achievable
- Dr Lynne Wrennall (22 June 2004)
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Witch hunting after child deaths
- Charles Pragnell (25 June 2004)
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Re: Sudden unexpected infant death - implementing guidelines
- Charles Pragnell (28 June 2004)
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Richard N Wood, GP 45 Dudlow Green Road, Appleton, Warrington, WA4 5EQ
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Sudden infant death has a devastating effect on the bereaved family. In a small minority of cases there is an attributable reason. Because of this, it is appropriate that all unexplained sudden deaths are investigated by the Police. However it is uniformed officers that attend and accompany the parents in the initial stages of their grief, distress and anguish. This overtly authorative presence reinforces to the parents the tacit thought that society feels there is a possible criminal cause to the event. This can only increase the distress of all even though the majority have no guilt at all. Would it not be more understanding and compassionate that all the investigation and attendance by the Police is in plain clothes? Competing interests: None declared |
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Natasha S. Crowcroft, Consultant in Public Health Medicine Health Protection Agency Immunisation Department, CDSC, 61 Colindale Avenue London NW9 5EQ, Robert George and Cyprian Okoro
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The investigation of sudden unexpected deaths in infancy (SUDI) requires a multi-agency approach and post mortem investigation must be based on best evidence, as described in the important clinical review by Fleming and colleagues (1). With respect to the evidence base for infectious causes of death, the best evidence should be provided by experts working in agencies responsible for the two linked domains of specialist and reference microbiology and public health, working in close collaboration with local pathologists and microbiologists While different branches of pathology have advanced dramatically in recent decades this has tended to occur in professional silos since pathology sub-specialised. Histopathologists, even those specialised in paediatric pathology, may be unaware of the range of diagnostic methods that have been developed by microbiologists and virologists. The current investigative protocols cited in the article (5 ) do not include such approaches. Molecular methods such as polymerase chain reaction (PCR) are now used routinely for investigating infections in children. These infections include pertussis, meningococcal disease, influenza, Staphylococcus aureus, Haemophilus influenzae, Clostridium perfringens, Streptococcus pneumoniae, respiratory syncytial virus (RSV) and metapneumovirus, all of which may cause sudden death in childhood and some of which are also targets of national immunisation programmes. The methods are established in clinical practice to be highly specific and may be more sensitive than traditional culture (2), with the potential to explain deaths that might otherwise remain “unexplained”. They are available in some local and regional microbiology laboratories and from the Specialist and Reference Microbiology Division of the Health Protection Agency (HPA), not just as “tests” but as part of a complete clinical service. Nevertheless, many pathologists, acting under the instruction of a coroner, do not extend their microbiological investigation of infant death much beyond “bacterial and viral culture”. The information that arises from the investigation of the cause of death is essential for good practice in public health. Such information includes that derived from laboratory surveillance carried out by the HPA and mortality statistics produced by the Office of National Statistics. Long-established causes of sudden death in infants often do not appear on the medical certificate of cause of death (the “death certificate”) even when results of traditional investigations such as culture are available. For example, deaths from culture-positive pertussis may be ascribed to the syndrome of “pneumonia"(3). This may occur because ante-mortem test results are not made available to the Coroner who completes the death certificate in many such cases. More sensitive methods not only help with individual diagnosis, but also improve the sensitivity of public health surveillance. This is important because, for rare causes of death, errors in estimates of the number of deaths can significantly change the results of analyses of the potential benefits of implementing a new immunisation programme or modifying an existing one (4). When a child has died, the finding that infection alone is a sufficient explanation of the cause of death has positive implications in comparison with most other causes. It gives parents and health professionals a clear understandable reason for the death and an idea of the chances of it affecting another child. It focuses the direction of further investigations, and can lay suspicion of foul play to rest. In some cases it may prevent a criminal conviction or provide the evidence for an acquittal. Finally, such information informs planning of public health interventions, such as vaccination programmes, to protect future children and parents. Several current policy initiatives will affect all agencies involved in the investigation of deaths. The agencies need to work together to ensure that the balance of the outcome of these initiatives is favourable for public health. In this context it is important that parents should be able to expect that their child’s death will be investigated to at least the same standard as if they had not died. The recently appointed post of Inspector of Microbiology provides an opportunity to promote improvements and uniformity in laboratory investigations of infectious causes of SUDI. Involving the HPA and the Inspector of Microbiology in assisting in standard setting for microbiological investigation of deaths will ensure not only that current protocols are updated but that they remain consistent with best practice as new pathogens are identified and new diagnostic methods developed in the future. The HPA has recently circulated a discussion document on the role of infections and the potential for specialist and reference diagnostic methods to assist with post mortem diagnosis with the overall aim of integrating microbiological investigation of SUDI. The document includes an evidence based investigative protocol that is complementary to many in current use but extends the level of investigation of infection through making use of the world class specialist laboratory methods provided to England and Wales by the HPA and the National Public Health Service for Wales. Copies of the discussion document are available on request. The HPA is currently considering whether this provision would be best facilitated for paediatric pathologists by providing a single receiving laboratory for all specimens from cases of SUDI. Natasha S Crowcroft,Immunisation Department, HPA CDSC; Robert George, Respiratory and Systemic Infection Laboratory, HPA SRMD; Cyprian Okoro Portsmouth City Primary Care Trust References 1. Fleming PJ, Blair PS, Sidebotham P, Hayler T. Investigating sudden unexpected deaths in infancy and childhood and caring for bereaved families: an integrated multiagency approach BMJ 2004;328:331-4 2. Crowcroft NS, Booy R, Harrison R, Spicer L, Britto J, Mok Q, Heath P, Murdoch I, Zambon M, George R, Miller E. Severe and unrecognised - Pertussis in UK infants. Arch Dis Child 2003; 88 802-806 3. Crowcroft NS, Andrews N, Rooney C, Brisson M, Miller E. Deaths from Pertussis are underestimated in England. Arch Dis Child. 2002; 86: 336-338 32. 4. Edmunds WJ, Brisson M, Melegaro A, Gay NJ. The potential cost- effectiveness of acellular pertussis booster vaccination in England and Wales. Vaccine 2002; 20: 1316-30 5. Berry J, Allibone E, McKeever P, Moore I, Wright C, Fleming P. The Pathology Study: The contribution of ancillary pathology tests to the investigation of unexpected infant death. In: The CESDI SUDI Studies. Sudden Unexpected Deaths in Infancy. (Fleming P, Blair P, Bacon C & Berry J Eds.) Chpt 4.Pp 97-112. The Stationery Office. London. 2000. Competing interests: None declared |
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Anne Livesey, Consultant Community Paediatrician Brighton, BN1 3JN, Detective Sergeant Edmund Hick, Sussex Police
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We welcome the publication of a multi-agency approach to the investigation of unexpected child deaths from a leading research department. (1) In Sussex we have had a multi-agency protocol for this since 1999, adopted by the police, health, social services and coroners. This precedent was acknowledged in the Avon protocol described in Prof. Fleming's paper. With support from the Foundation for the Study of Infant Deaths, we have recently evaluated how the Sussex protocol has worked over its first three years. We looked at the processes and outcomes of multi- agency investigations into unexpected child deaths and obtained feedback from parents and professionals. A key finding was that implementation of the protocol was incomplete and variable throughout the county. There was no agreed implementation strategy and how the protocol was applied in practice was left to individual professionals on duty at the time. Some aims were achieved; for example, early inter-agency discussions took place and most post mortems were carried out by paediatric pathologists. However, there were gaps and inconsistencies in post mortem investigations. For example, over one third of babies did not have a post mortem for three or more days; this meant that evidence might have been lost, particularly as there were no recorded early investigations in the A&E departments for two thirds of babies. The system whereby coroners or their officers have control over medical investigations was not always helpful. It is generally accepted that professionals' response to unexpected infant deaths requires a sensitive balance between evidence-based medical and forensic investigation and family support. This is likely to be a focus of the current working party on this issue led by Baroness Kennedy. However, it is also critical that multi-agency guidelines and protocols have an implementation strategy that takes account of local expertise and resources, have clear accountabilities and include a review process. Dr Anne Livesey, Consultant Community Paediatrician, Royal Alexandra Hospital for Sick Children, Brighton Detective Sergeant Edmund Hick, Sussex Police (1) Fleming PJ, Blair BS, Sidebotham P, Hayler T Investigating sudden unexpected infant deaths in infancy and childhood and caring for bereaved families: an integrated multi-agency approach BMJ 2004; 328:331-4 Competing interests: None declared |
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Dr Lynne Wrennall, Fellow University of Liverpool L69 3BX
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There is probably broad agreement that an expansion in Paediatric Pathology services is required. What is less clear, is the appropriate location and basis of accessibility of the services. The potential for inequality to develop in access to services is considerable. After the experiences of the last few years, wealthy and astute families who experience the death of an infant will now realise that they must consult and retain the services of a Paediatric Pathologist to protect their interests. This service provider will need to be retained from the outset to be involved in negotiations about the forensic, investigative and supportive processes to be followed. This Paediatric Pathologist will need to negotiate tests and procedures for the post mortem and either conduct, or at least be present during, the post mortem. If a Paediatric Pathologist is not available locally, privileged families may fly one in from overseas. I would think it unlikely that attempts to block access by a Paediatric Pathologist instructed by a party which had legal standing could withstand a determined party which is aware of the various levels of protection which are claimable under Human Rights provision at the national and international levels. 1. Potentially then, a Post mortem could be attended by a number of service providers, representing the different parties, which may include one provider to represent each party. Namely, one for each of the Mother, the Father, the Hospital Trust, the Local Authority and others. Conversely, a family which is less advantaged and did not have access to the service would be very vulnerable indeed. The implications for such families are dire, as we have seen. Questions about the location and financing of the services are therefore vital to the discussion. If Paediatric Pathology services are to be credible, they must be above conflicts of interest. If impartiality is unattainable, integrity must be achievable. Each party must be able to be assured that the service provider will represent their interests, without exposure to the undue pressure which conflicts of interest tend to generate. It may be that such a high degree of integrity can only be assured if Paediatric Pathologists work in private practice and are exclusively accountable to the instructing party. The service can however be financed out of central revenue, to ensure equality of access by all parties which have legal standing. Nothing in such an arrangement should prevent the various parties from agreeing to jointly instruct a Paediatric Pathologist to represent their interests in common. I will await further contributions to the debate before I form a strong opinion on this. I will be very pleased to hear people’s views on the matter. 1. This is not a legal opinion. Competing interests: I am an educator and researcher in Children's Policy and Practice. |
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Charles Pragnell, Expert Defence Witness-Child Protection and Child/Family Advocate U.K./Australasia
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Whilst the approach to Sudden Unexpected Deaths of Infants as set out by Fleming et al is ostensibly to help and support bereaved families and to protect parents who are innocent of causing the child’s death, there are elements which suggest it is yet another form of child protection witch hunt in the hope of gaining evidence which may incriminate some of the parents. e.g. 1. The statement that “Limitations in the present coronial system have led to delays or failures to detect deaths caused by relatives, carers, or health professionals” is an extremely subjective assumption with no evidence provided to support such a contention. This becomes more concerning when it is later stated that, “Twenty one deaths (4.6% of the total sudden deaths of infants) were THOUGHT TO BE directly due to non- accidental injury. In the infants whose deaths were classified as sudden infant death syndrome (acts of commission or omission) was thought to be a contributory factor in a further 22 deaths (4.8% of the total sudden deaths of infants.” What part does “thought to be” play in a purportedly forensic and scientific study?. 2. Why are joint home visits necessary by police and paediatricians to investigate the `scene of death/crime’, if there is not already an assumption that foul play has occurred and that the visit is merely a cover for seeking evidence to support this assumption?. What is the real meaning of “By visiting the home and seeing where the baby died, both the police and the paediatrician can gain further information, and family members are given the opportunity to talk through what happened in detail.”. . Are unwitting parents given cautions in these circumstances that anything they may say or do, may be used in evidence against them in criminal or civil proceedings?. Or does the caution occur after they may have incriminated themselves?. 3. It is highly significant that Fleming et al state, “……. have led to delays or failures to detect deaths caused by …… health professionals” and “on the identification or exclusion of contributory medical factors”. They are thereby acknowledging the existence of iatrogenic child abuse and child killing, yet nowhere do they suggest how such iatrogenic causations are investigated with the same rigour in which the parents or carers are investigated. A large proportion of child deaths occur in hospitals but Fleming et al fail to suggest that such deaths in hospitals are investigated in the same way by the police and paediatrician – in these circumstances is the paediatrician a suspect in the same way in which parents are?. Are investigations carried out into the activities of all of the nursing staff and physicians who have come into contact with the child or ambulance crews who may have given resuscitation to the child.? It is only a few short years since 30 babies died in Bristol hospital as a consequence of surgical treatment and more recently 29 children died and several others suffered serious injury who had been part of medical experiments at North Staffordshire. Why are Fleming et al not advocating similar police and child protective investigations into these types of infant deaths. I fully recognise and acknowledge that a small number of parents cause fatal harm to their children and with Fleming et al’s statements that so also do some health professionals. The first stage of investigation of child deaths should however be a thorough and exhaustive investigation of genetic causes, toxic poisoning, severe multiple allergic reactions and from an iatrogenic perspective, child deaths which may result from birth injuries, surgical injuries, prescribed medications e.g. Cisapride, vaccine damage, medical experimentation, medical treatment by commission or omission, and known diseases as described above by Natasha Crowcroft. I totally support the statement of Dr. Lynne Wrennall that paediatric pathology services which investigate child deaths must be “above conflicts of interest” but the system described by Fleming et al has inbuilt bias and prejudice. All investigations into child deaths whether they occur in hospital or at home, should be carried out by a forensically trained paediatric pathologist who is totally independent of the health services in that area in order that such investigations may be objective, impartial and even-handed and are conducted thoroughly into the numerous possible causations, before a parental or iatrogenic causation of child death is considered. Only if such a thorough forensic investigation indicates a causation by non-accidental means, should the police and child protection agencies become involved. Competing interests: Concern to reform the child protection system |
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Charles Pragnell, Expert Defence Witness-Child Protection and Child/Family Advocate U.K./Australasia
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The Rapid Response by Anne Livesey and Police Sergeant Edmund Hick describing the system of investigating sudden unexpected deaths in infancy in practice in Sussex, confirms my worst fears that this system is no more than a perverse pretext of investigating possible child abuse under a guise of providing information and support to parents. They make only passing reference to supporting the family with no details of what support was offered, how it was received, or what the benefits were to the parents. By their own admission, the system they have implemented is deeply flawed and erratic, e.g. “A key finding was that the implementation of the protocol was incomplete and variable throughout the county. There was no agreed implementation strategy and how the protocol was applied in practice was left to individual professionals on duty at the time”. We are left to speculate as to how many parents were falsely accused of child abuse as a result of this system failure or whose suffering was compounded by inappropriate interventions and investigations. In effect, Fleming et al are advocating a system which has already been shown to be flawed and erratic after a five year period of implementation. If, as is claimed by Fleming et al, the primary purpose of the interventions is to provide “information and support” to grieving parents, then would not the first service provision be therapeutic counselling (if this is the parent’s choice) and an introduction to parents who had similarly suffered a sudden unexpected child’s death and would therefore have the greatest understanding and sympathy for those parents, rather than be subjected to paediatric and police investigations. Only after an investigation by a forensic paediatric pathologist independent of the health services in that area indicated no known medically explainable cause, should the police and the `multi-agency’ machinery become involved. They should however still bear in mind that `medically unexplained’ does not mean that the cause of death was other than from a natural cause and was not necessarily the result of foul play. The withholding of medical evidence in the Sally Clark case and which would have shown her innocence from the outset, was not an isolated incident as parents who have been similarly accused and their legal advisers report that it is often impossible to obtain the complete medical records of the child, or if medical records are obtained, parts of those records have been altered, or important documents are missing. Again we can only speculate as to why medical records following alleged child abuse and deaths are so often missing, or incomplete. A very necessary improvement to the coronial system would be to immediately seize all medical records relating to the dead child before such alterations, and omissions occur. In summary, the recommendations of Baroness Helena Kennedy should advisedly begin with a presumption of death by natural causes and that information and support services to parents are given first priority followed by a thorough and exhaustive investigation carried out by an independent forensically-trained paediatric pathologist with access to the complete medical records. Only if such a forensically-based investigation indicates no medically explained cause of death, should the `multi-agency’ gang of witch-hunters be permitted to be involved. Competing interests: Concern to reform a deeply flawed, erratic, and dysfuntional child protection system |
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