Intended for healthcare professionals

Rapid response to:


A multiagency protocol for responding to sudden unexpected death in infancy: descriptive study

BMJ 2005; 330 doi: (Published 27 January 2005) Cite this as: BMJ 2005;330:227

Rapid Response:

An unworkable and unnecessary protocol

A failure of child protection agencies to communicate and work
together with each other, and a failure of some of those agencies to carry
out their statutory or expected duties.

Now where could we have heard that before?. And why are we not
surprised?. Could it have been the Inquiry into the death of Victoria
Climbie’ or the over forty similar Inquiries since 1946 into the deaths of
infants whilst under the care and/or supervision of child protection
workers and the events in Cleveland in 1987.

The present failures are despite guidance and exhortations on
numerous occasions by the DfES (DoH) for such agencies to work together in
child protection matters. Yet further proof of the erratic and
dysfunctional operations of the child protection system in the U.K. and
further justification for a Public Inquiry into the child protection

The `protocol’ proffered by the RCPCH and the Kennedy Report are
clearly shown by this research to be unworkable and unnecessary.

Dr. Livesey’s study shows that in over a quarter of cases the cause
of the infant’s death “were attributed to specific natural causes”,
therefore no protocol is necessary and will only add to the suffering and
distress of the grieving parents in those cases. In the other cases, no
medical explanation could be found and it is these cases which require
closer examination. Firstly by a specialist team including an experienced
geneticist, a toxicologist e.g. for toxic poisons from mattresses), a
haematologist, a disease specialist, an examination for vitamin deficiency
(particularly Vitamins C, B6, and iodine), and an allergist and then by an
independent paediatrician for iatrogenic causes such as birth injury,
prescribed medications, vaccine damage, etc. No single paediatrician could
be reasonably expected to have the knowledge which those other specialists
would bring to the investigation.

If such medical investigations were carried out carefully and
thoroughly, the numbers of medically unexplained deaths of infants would
be reduced to an irreducible minimum and it is only this minimum group
which would need to be investigated by paediatric specialists and the

In such cases it should not be a child protection investigation by
stealth, deceit, and dishonesty as is evident in the RCPCH and Kennedy
protocols, but that the parents should be cautioned that they are being
questioned and that any information they give may be used in Criminal or
Care Proceedings against them. Without such a caution then any subsequent
prosecution would be morally, if not legally, void.

It is only this irreducible minimum number of cases where the various
child protection agencies need to be involved and then only if there are
other children in the family who may need protection. To involve every
child protection agency in all of the other investigations is totally
unnecessary and wasteful of financial and other resources and as has been
shown, is unworkable on the scale proposed and who knows, those agencies
might just be able to defy history and be able work together on such a
small number of cases.

Competing interests:
Concern to reform thre child protection system

Competing interests: No competing interests

03 February 2005
Charles Pragnell
Expert Defence Witness - Child Protection