Paediatrics (Neonatology)

The following sections will help neonatologists 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 neonatologist through their involvement following a SUDI.

Interactive timeline and flow chart
SUDIs occurring in a maternity unit
Pre-mortem investigations
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 neonatologist 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) »

SUDIs occurring in a maternity unit

1. Rarely an infant may be found lifeless in a hospital cot or when bed sharing with the mother.

2. For any in-hospital SUDI the guidance for Emergency Department staff should be followed.

3. More commonly the infant is found in a state of collapse and undergoes resuscitation and intensive care before dying later from the hypoxic-ischaemic consequences of their collapse. The reason for death is often certified as hypoxic-ischaemic damage, but the reason for the initial collapse is unknown. An infant who suffers a such a collapse is defined according to UK Guidelines for the Investigation of Newborn Infants who suffer a Sudden and Unexpected Postnatal Collapse (SUPC) In the First Week of Life, 2010, and includes any term or near term (>35 weeks gestation) infant who:

is well at birth (normal 5 minute Apgar score and deemed well enough to have routine postnatal care)
collapses unexpectedly requiring resuscitation with intermittent positive pressure ventilation within the first seven days of life, and
who either dies or goes on to require intensive care or develops an encephalopathy.

4. It is important to promote the same investigation for deaths following SUPC that an out of hospital SUDI would require, and in particular that all are reported to the Procurator Fiscal and should undergo a perinatal post-mortem examination.

5. Where a police report is deemed necessary by the Procurator Fiscal, prior communication with the maternity unit by the police to arrange a suitable time to visit and take questions, as well as attendance by plain clothes officers should support staff and parents where it is not normal practice for police to attend maternity units.

6. It is important that parents are made aware of the routine nature of Procurator Fiscal/police involvement and that police officers may contact them in their own home if the mother has already been discharged from hospital.

7. Neonatologists may also be called to the Emergency Department for an out of hospital SUDI if the infant had very recently been discharged home after birth. The guidance for Emergency Department staff should be followed.

SUDI packs

1. Each maternity unit has been provided with details of a suggested SUDI pack.

2. This pack contains resources required by 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. These leaflets contain information regarding the necessary Procurator Fiscal and police involvement and explain the need for post-mortem examination in all cases.

5. Local bereavement support information should also be contained, along with details of support organisations.

Pre-mortem investigations

There may be a lag time between collapse and death, and infants should undergo an investigatory work up prior to death whilst receiving intensive care. A different set of investigations are required which are pertinent to a neonatal death (congenital anomaly and metabolic conditions are more likely causes in the neonate compared with older SUDIs). This may help establish a cause of death for the infant, but also (where consent for research is given by parents) may inform future research into SUDI.

Other responsibilities

1. Gather information from staff and family members involved in the care of the infant.

2. Gather information about the situational circumstances, family/obstetric history and document all events including history, examination, and records of all interventions, investigations and procedures carried out.

3. Inform GP, community midwife, health visitor and obstetrician of the death.

4. Sensitively approach the issue of additional consent for previously collected samples to be used in potential future research purposes.

Ongoing Involvement

1. You will be asked by the police or pathologist for background information about the infant and the mother/father or carer. There has been agreement from the General Medical Council that due to the investigations that require to be carried out by the police on behalf of the Procurator Fiscal, information should be shared between agencies. It is recognised that duplication of questioning of parents through lack of information sharing would add to their upset. The range of questions enables as full a history as possible to taken as quickly as possible.

2. You may be contacted again by the police or pathologist at several stages of the process to share relevant information.

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

The role of Child Protection

Neonatal deaths occurring in hospital are rarely due to criminal intent or child abuse and as such child protection involvement should be limited to cases where there is suspicion surrounding the cause for collapse or where a family has had previous child protection involvement.

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 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.

Support during the next pregnancy

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

1. Aim to meet with the parents during their next pregnancy and aim for continuity of care and involvement in the choices available, eg community care if appropriate.

2. Acknowledge that the birth of the new baby and early postnatal period may bring back difficult memories of the baby who died and that all staff involved should be aware of the previous history.

3. Discuss with the NHS board’s SUDI paediatrician plans for providing extra support for the care of the next infant, such as additional neonatal monitoring, longer neonatal stay or provision of an apnoea monitor.

4. Whenever appropriate discuss risk factors such as sleep position, co-sleeping, smoking, and be up-to-date with the latest research.

5. 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 SUDI

Each case is unique, so there is never an absolute timescale to follow. However, here are some milestones which may be useful to share with the parents.

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.

7. A record of the meeting and the content of the report should be communicated to the GP and the mother’s obstetrician.

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 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 following an in-hospital SUDI may include:

neonatologist
nursing team
midwife
obstetrician
pathologist
general practitioner
community health visitor
social worker
community midwife

The meeting will be held at a suitably convenient time and location 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.

The results of this meeting should be available to the parents should they so wish.