Emergency Department

The following sections will help Emergency Department staff 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 Emergency Department staff through their involvement following a SUDI.

Interactive timelines and flow chart
SUDI packs
Key points for Emergency Department staff involved in SUDI
The role of Child Protection
Staff Support
Steps and timelines around the investigation of a SUDI
The SUDI Review
Resources & External web links

Interactive timelines and flow chart

The interactive timeline demonstrates the role and responsibility of staff in the Emergency Department 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) »

SUDI packs

1. Every Emergency Department, and other NHS facility receiving emergencies in remote and rural settings, have been provided with details of a suggested SUDI pack.

2. This pack contains resources required by the Emergency Department staff to undertake the appropriate procedures after death has been pronounced.

3. The pack provides the necessary documentation to gather information required by the local Procurator Fiscal and the paediatric pathologist.

4. Parental information leaflets, providing written information backing up what should be discussed (What happens next? leaflet and Parent Support leaflet [SCDT]). These leaflets contain information regarding the necessary Procurator Fiscal and police involvement and explain the need for post-mortem examination in all cases. Bereavement support information should also be contained, along with details of support organisations.

Key points for Emergency Department staff involved in SUDI

The following roles are often shared between Emergency Medicine staff and paediatricians if on site. The SUDI paediatrician for the health board should assume an overall responsibility to ensure local awareness of this guidance. Local variations on who takes individual responsibility for the actions should not prevent use of the guidance being implemented. In some remote and rural locations the following may be undertaken by a general practitioner(GP) or nurse practitioner.

1. Prepare for arrival of infant (allocate team roles, contact paediatricians +/- anaesthetist).

2. Resuscitate as appropriate as per UK Resuscitation Council guidelines for advanced paediatric resuscitation.

3. Always give parents the opportunity to be present during resuscitation and explain what is happening. If they are not present ensure that they are kept informed of what is happening.

4. If English is not the family’s first language, and they do not speak English well, contact the interpreters service.

5. Support the family once death has been declared.

6. Inform the police if not already present.

7. Find out if arrangements for care of siblings are required.

8. Take full history from family about events prior to death, including previous medical history.

9. Explain to family what will happen next, ie the role of the police, Procurator Fiscal and the need for a post-mortem examination by a paediatric pathologist. This may necessitate the transfer of the infant body to a mortuary in a different town or city. There may also be a delay in issuing death certificate.

10. Liaise with the police in providing them with the opportunity to speak with the parents at an appropriate time.

11. Retain nappy and clothing for the police (bags included in SUDI pack).

12. A Moses basket (or a cot suitable for the size of the infant) should be available with a shawl/ child sized blanket to wrap the infant in.

13. Always allow family to hold the infant (supervised) and take photographs if they wish.

14. Be aware of differing cultural beliefs as suggesting photographing the dead is very offensive to some faiths.

15. Explain that you can arrange for the family to see the infant again at the mortuary.

16. Provide the What happens next? and the Parent Support (SCDT) leaflets

17. Offer support organisation contact details.

18. Offer local bereavement leaflets.

19. If there are no paediatricians onsite, ensure that they are informed the next day (if out of hours) and make sure the parents have the contact number for the health board SUDI paediatrician.

20. Inform the local area Procurator Fiscal Office (on the next working day if out of hours).

21. Inform the GP immediately (next working day if out of hours). Consider telephoning NHS 24 if out of hours and asking them to contact GP the next day via mailbox number for practice or by telephoning the named GP for the infant.

22. Debrief staff and ensure that they are aware of local staff support services available to them.

23. Once the infant’s body has left the Emergency Department and staff have provided information to the police for the Sudden Death report, care and support of parents is usually provided by the paediatric staff.

24. The post-mortem examination results should be made available to the Emergency Department consultant through the paediatrician or pathologist. These should be fed back to the resuscitation team.

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:

Initiate and maintain good communication between all agencies involved to ensure clarity of roles.
Gather relevant background information.
Provide support to primary care colleagues regarding access to medical notes, interviews with members of the police etc.
Support the management of a SUDI until post-mortem findings are known.
Advise as well as develop policies and practice in child protection.
Ensure that the bereaved family understands that child protection involvement is standard practice in all SUDIs.
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 examination 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.

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 SUDI

Each case has unique circumstances which require investigation 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.

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.