Community Midwifery

The following sections will help community midwives to respond appropriately to a SUDI. Other professionals involved may have addressed some of the issues, but you should not assume that they have. The information may also be useful to other professionals interacting with the community midwife through their involvement following a SUDI.

Interactive timelines and flow chart
What to do if you are first on the scene
What to do if informed that a SUDI has occurred
Other things you can do to help
Ongoing involvement
The role of Child Protection
Support during the next pregnancy
Staff Support
Steps and timelines around the investigation of a SUDI
The SUDI Review
Resources & External web links

Interactive timeline and flow chart

The interactive timeline demonstrates the role and responsibility of a community midwife in relation to other professionals involved, and in the subsequent SUDI Review meeting. The scenario illustrated in the flow chart highlights some of the key points but does not aim to show everything that may arise in what is a unique circumstance for each case of SUDI.

View example scenario (flow chart) »

What to do if you are first on the scene

1. Ensure the ambulance has been called for, if not contact them (Scottish Ambulance Service control room will notify the police).

2. Resuscitation following the UK Resuscitation Council basic or advanced paediatric guidelines should always be attempted and continued en route to hospital, if there is any chance that the infant could be resuscitated.

3. If it is quite clear that the infant is dead and cannot be resuscitated, inform the parents sympathetically.

4. In all cases the infant should be taken to the nearest paediatric Emergency Department (if available), or nearest general Emergency Department, not straight to the mortuary. This allows immediate examination and investigations to be carried out and provides a more supportive environment for the family.

5. Explain that the police have a role to investigate every SUDI, as instructed by the Procurator Fiscal, to try to establish the cause of death. It is normal for the police to be notified and it does not mean parents are under suspicion.

– If there is evidence of criminality: If it is apparent that resuscitation is inappropriate and there is evidence of criminality, the child should be left as found and contact made with the police immediately.

6. Take a brief immediate history from those present and record the circumstances of the death (e.g. position when found, bedding, vomit etc). Your notes will be helpful to the hospital paediatrician who will record information to pass to the police. The History and Examination form should be used by health visitors responding in remote and rural settings where there is no paediatrician.

7. Inform the parents that the Child Health Record (Red Book) will be required by the police to provide background information on the infant’s general health.

8. Spend time listening to the parents. Mention the infant by name and don’t be afraid to express your sorrow.

9. Explain that a paediatrician may wish to see the infant and the parents as soon as they get to the emergency department.

10. If the infant is a twin, suggest that the surviving twin should be admitted to hospital for observation.

11. You may wish to accompany the family to the hospital.

12. The parents may wish you to contact relatives or friends, or to arrange for someone to meet them at the hospital.

13. Inform the family GP and your line manager.

What to do if informed that a SUDI that has occurred

1. A hospital department (eg maternity unit or Emergency Department) or GP may inform you that an infant has died.

2. Liaise with other members of the practice, especially the GP and community health visitor (if involved), to organise support for the family and for each other, and to ensure that everything necessary is done without duplication.

3. The police will request original health records within a day or two of the infant’s death (make copies of notes to keep locally until the originals are returned). These notes allow completion of the police Sudden Death Report to be submitted to the Procurator Fiscal, and also provide the paediatric pathologist carrying out the post-mortem examination with as much information as possible.

4. Inform other departments, so no further computer generated appointments for immunisation or developmental checks are sent out. Also inform the hospital medical records department to ensure no clinic appointments are sent.

5. Visit the family the day the death occurs, or as soon as possible afterwards (with the GP, if preferable) to acknowledge the death and offer condolences. Make sure you use the infant’s name.

6. Spend time listening to the parents. Mention the infant by name and don’t be afraid to express your sorrow.

7. If the parents are out, leave a note and try again as soon as you can.

8. Contact relatives and friends to help support them, if necessary.

9. Ask the parents about the reactions of siblings – tell them that there is special support that the siblings can receive from support organisations.

10 . Support the parents emotionally and ask if the procedures following a SUDI have been explained.

11. Answer any further questions the parents may have, especially regarding the role of the Procurator Fiscal, police and the post-mortem examination.

12. Explain that the police have a role to investigate every SUDI, as instructed by the Procurator Fiscal, to try to establish the cause of death. It is normal for the police to be notified and it does not mean parents are under suspicion.

13. Inform parents that the Child Health Record (Red Book) will be required by the police to provide background information on the infant’s general health.

14. Ask whether they wish to see the infant before the post-mortem examination and find out how this can be arranged.

15. Check whether spiritual help has been offered, and arrange appropriate contacts, if required.

16. If mother is breastfeeding discuss methods for suppression of lactation.

17. Ask if the parents would like to be put in touch with any support organisations.

Other things you can do to help

1. Check that an undertaker has been arranged and explain about the Funeral Payment available through their local Benefits Agency. Some funeral directors will not charge for an infant’s funeral. Ask if they would like you to attend the funeral.

2. Visit again after the funeral and regularly during the following weeks. Listen and share memories. Remember anniversaries of the infant’s birth and death.

3. Assess whether the parents need more help with their grief (remembering that people grieve in different ways). Discuss with GP if you have any concerns.

Ongoing involvement

1. You will be asked for background information about the infant and the mother/ father or carer.

2. You may be contacted at several stages of the process to share relevant information.

3. You may be asked to take part in a SUDI Review.

4. Make sure that information about SUDI and risk reduction is included in parenthood sessions, preconceptual and health promotion clinics.

The role of Child Protection

Child protection underpins all investigations following SUDI. It is standard practice for a child protection team to be contacted in all cases to make them aware of the infant’s death. The degree of involvement of a child protection team will vary for each SUDI, from maintaining a very peripheral role and concluding their part in the investigation as soon as the initial post-mortem findings are known, to providing ongoing support to the family and staff involved, if child protection issues are raised. Child protection teams include professionals from health care, social work and police.

Child protection staff collaborate with health care professionals, social workers and police to:

1. Initiate and maintain good communication between all agencies involved to ensure clarity of roles.

2. Gather relevant background information.

3. Provide support to primary care colleagues regarding access to medical notes, interviews with members of the police etc.

4. Support the management of a SUDI until post-mortem findings are known.

5. Advise as well as develop policies and practice in child protection.

6. Ensure that the bereaved family understands that child protection involvement is standard practice in all SUDIs.

7. Provide the necessary support packages available for the family should they be required.

Child Protection team involvement

1. The child protection team in the hospital is notified by Emergency Department staff when a SUDI occurs.

2. There is interaction with relevant hospital and primary care colleagues, police and social work, as appropriate and an agreement on who makes contact with the following:

lead paediatrician for the area
clinical director for children’s services
executive director with responsibility for child protection
nurse consultant for vulnerable children
designated doctor for vulnerable children
the Child Health Commissioner
chief nurse for the area
family health visitor for pre-school children.

3. The advisor involved with the case will assess and decide on the level of engagement with maternity and child health services, background history including any previous child protection concerns.

4. The team will remain involved with the case until the outcome of the post mortem is known.

5. The parents/family are informed by Emergency Department staff or a paediatrician it isstandard practice that initial information gathered regarding the circumstances of the death will be shared with the local child protection team.

6. The parents/family should be reassured that this does not imply suspicion or criticism of their care of the deceased infant.

Support during the next pregnancy

If a family has previously experienced a SUDI, then the following actions may help provide support.

1. Acknowledge the previous death using the infant’s name.

2. Aim for continuity of care and involvement in the choices available e.g. community care if appropriate.

3. Note anniversaries when the parents may need additional support.

4. Discuss with the NHS board’s SUDI paediatrician plans for providing extra support for the care of the next infant, such as provision of an apnoea monitor.

5. Whenever appropriate discuss risk factors such as sleep position and smoking.

6. In some areas a designated member of staff may co-ordinate the plan for additional support that a family may require for future pregnancies, working with a SUDI paediatrician/ GP/ community midwife/ community health visitor to ensure that additional appointments are offered and that any additional screening is offered if appropriate.

Staff support

The professionals involved may require support. Some professionals may have prolonged involvement in the investigative process and will have no experience of SUDI. This toolkit provides information on staff support.

Steps and timelines around the investigation of a SUDI

Each case is unique, so there is never an absolute timeline to follow. The following steps should occur:

1. The police will provide the Procurator Fiscal with a Sudden Death report the next lawful day (Monday if the death occurs over the weekend).

2. Original medical records will be requested by the police on behalf of the Procurator Fiscal, and given to the pathologist prior to the post-mortem examination.

3. A post-mortem examination will be requested and normally take place within 48 hours.

4. The paediatrician following up the case will offer to meet with the parents after 1-2 weeks to discuss the process to date and offer ensure appropriate support is available for the family

5. The final post-mortem examination report can take several months as further examinations of samples will need to be concluded.

6. The Procurator Fiscal will confirm with Healthcare Improvement Scotland that it is appropriate for the SUDI Review meeting to take place once the post-mortem examination report is available, assuming there is no suspicion of criminality. Healthcare Improvement Scotland will liaise with SUDI paediatrician for the NHS Board.

The SUDI Review

The SUDI Review is a multidisciplinary meeting at which the case is discussed. The 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 during and after any future pregnancies.

Participants may include:

paediatrician
pathologist
general practitioner
community health visitor
community midwife
social worker.

In particular, the community midwife may be involved in any existing additional support the parents are receiving, such as through local substance misuse teams – it is often a midwife who is responsible for overseeing the mother’s involvement with such services.

The meeting will be held at a suitably convenient time and place for all involved. The SUDI Review meeting will not take place if there is any suspicion of criminality or if a Significant Case Review has to take place through Child Protection.