Implementing guidelines on sudden infant death

EDITOR—Fleming et al described a multi-agency approach to investigating unexpected infant deaths.1 Such a multiagency protocol—adopted by the police, health, social services, and coroners—has existed in Sussex since 1999. This precedent was acknowledged in the Avon protocol described by Fleming et al.1

With support from the Foundation for the Study of Infant Deaths, we recently evaluated the Sussex protocol over its first three years. We looked at the processes and outcomes of multiagency investigations into unexpected infant 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 interagency discussions took place, and most postmortem examinations were carried out by paediatric pathologists.

There were, however, gaps and inconsistencies in postmortem investigations. For example, over one third of babies were not examined for three or more days; this meant that evidence might have been lost, particularly as early investigations in accident and emergency departments were not recorded for two thirds of babies. The system whereby coroners or their officers have control over medical investigations was not always helpful.

Professionals' response to unexpected infant deaths requires a sensitive balance between evidence based medical and forensic investigation and family support. Multi-agency guidelines and protocols must, however, have an implementation strategy that takes account of local expertise and resources, with clear accountabilities and a review process.