The SUDI Project

In 2009 The Scottish Government asked the then NHS Quality Improvement Scotland (NHS QIS), now Healthcare Improvement Scotland, to progress a programme of work on the subject of Sudden Unexpected Death in Infancy (SUDI).

It was agreed that NHS QIS should facilitate development of the following:

• A web based toolkit, providing resources to all professionals involved in the investigation of a SUDI.
• SUDI Review multidisciplinary meetings to be co-ordinated timeously after each SUDI.
• The collection of national data to identify any trends and risk factors, which may influence future practice.
• The evaluation of the SUDI Review process and the toolkit.

This programme of work was funded initially for a period of two years. This toolkit was evaluated for its effectiveness in contributing to the investigation of SUDIs and found to be of use to the many multi agency teams involved.

When the toolkit is not applicable

In a very small number of cases the death of an infant may be due to an act of deliberate harm. In these rare instances the investigation may be conducted differently, and the practice suggested in this toolkit may not be appropriate. However, the professional guidance on support of the family and completion of documentation for police acting on behalf of the Procurator Fiscal should still be applicable, and in particular the family may need additional support from the professionals involved. The SUDI review meeting in particular is not appropriate if any legal proceedings are to take place or where a child protection investigation has been instigated.

Staff in any SUDI regardless of the outcome of the investigation may need to access support.

Previous SUDI project in Scotland

In 2001, the Scottish Cot Death Trust (SCDT) piloted the concept of local, multidisciplinary case reviews following a SUDI. The data collection period was September 2001 to August 2004 and included all sudden unexpected deaths in infants under two years of age. The pilot study required participation from all health boards and local authorities in Scotland, along with co-operation from the Crown Office and Procurator Fiscal Service.

One hundred and thirty eight cases were identified, of which 80 (58%) were included for multidisciplinary case review.

SUDI Steering Group

NHS QIS held a stakeholder event in March 2009 in which group discussions centred on the four elements of the proposed programme. Three working sub-groups were set up to progress the individual work streams and collectively form the SUDI Steering group. These members contribute to and oversee the design, dissemination and implementation of each of the above elements.

SUDI Toolkit Sub-group

This group have advised and developed this web based toolkit to provide professionals with information and guidance. The toolkit also explains the investigation of SUDIs and each profession’s role in the process. In particular where they enter and exit the process, which professions they interact with, and what information they may be required to give, or ask of others.

SUDI Review Sub-group

The SUDI review meeting is held shortly after the final post-mortem examination report is available, which may be several months after the infant has died. The purpose is to discuss all aspects of the death, including possible causes or contributing factors to see what lessons can be learned and to plan support for the family, in particular support for any future pregnancy.

Data Collection Sub-group

Both in the investigation of a SUDI and for co-ordination of the SUDI review meeting, data are required to be collected and logged onto a database. The dataset required for the information health professionals will gather during the investigation has been identified.

Healthcare Improvement Scotland SUDI Project Team

Lynsay Allan, Project Lead
Naomi Fearns, Clinical Audit Co-ordinator (from November 2010)
Kenny Gifford, Administrative Assistant
Jeff Hurst, Administrative Assistant
Chris Lennox, Clinical Advisor
Leslie Marr, Reproductive Health Programme Co-ordinator
David Maxwell, Clinical Audit Co-ordinator (from October 2010)
Orlagh Sheils, Clinical Audit Co-ordinator (until August 2010)

SUDI Steering Group Membership

Harpreet Kholi (Chair), Director of Public Health, NHS Lanarkshire

Julie-Claire Becher, Consultant Neonatologist
Lesley Boal, Association of Chief Police Officers in Scotland (ACPOS)
Linda Cockburn, Crown Office and Procurator Fiscal Service (COPFS)
Sarah Corcoran, Scottish Government
Louise Croan, Midwife, Edinburgh PrePare Team
Margaret Evans, Consultant Paediatric Pathologist
Stephen Ferguson, Communications Officer, Healthcare Improvement Scotland
Mairi Harvey, Public Partner, Healthcare Improvement Scotland
Jean Herbison, Clinical Director in Child Protection
Allan Howatson, Consultant Paediatric Pathologist
Michelle Kirkpatrick, Social worker, Edinburgh PrePare Team
Adrian Lawrie, Police Child Protection Office
Bill Mason, Scottish Ambulance Service
Kerry Milligan, General Practitioner
Kate Mitchell, Family Support Nurse
Madeline Mitchell, Bereavement Support Nurse
Jacqui Mok, Community Paediatric Consultant
John McClure, Chairman, Scottish Cot Death Trust (SCDT)
Mairi-Anne MacDonald, Social Worker
Una MacFadyen, Consultant (SUDI) Paediatrician
Mairi MacMillan, Community Nurse Manager
Ann McMurray, Stillbirth and Neonatal Death Charity (SANDS)
Karen MacPherson, Health Services Researcher, Healthcare Improvement Scotland
Neil Proven, Scottish Ambulance Service
Adrian Sie, Consultant (SUDI) Paediatrician
Phyllis Smart, Nurse Consultant (Child Protection)
Reddeppa Thimmarayanagari, Consultant (SUDI) Paediatrician
Lucy Thomas, Emergency Medicine Consultant
John Weir, ACPOS
Breda Wilson, Child Protection Advisor
Annie Wright, Communications Officer, Healthcare Improvement Scotland