SUDI Review

Example SUDI review meeting timeline showing planned feedback points for professionals to inform parents

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1. SUDI occurs–acute period in the ED.

1. The first 24 hours post SUDI
   Emergency Department notifications »
   Emergency Department consultant to make contact with GP, social worker, if involved with family, and also the SUDI paediatrician to ensure they are aware of case
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   1. GP to inform other relevant staff in primary care team »
      GP to inform: health visitor or equivalent, community midwife, community nurse manager as relevant
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   2. Neonatologist to inform relevant staff »
      In the case of in hospital SUDI/ Sudden Unexpected Postnatal Collapse (SUPC), the neonatologist would undertake the role of informing staff such as the obstetrician, midwives, nursing team, GP, community midwife, health visitor
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2. Police Sudden Death report to Procurator Fiscal next (lawful) day »
   In most cases the police will already be aware of the SUDI and will submit a report. If they are not involved from the start the Procurator Fiscal will instruct them to submit the report.
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3. Identified* paediatrician clarifies parent information given in Emergency Department. »
   *Paediatrician involved with family from start (may not be SUDI paediatrician). The information in the Emergency Department SUDI pack includes the parent bereavement leaflets, SUDI parent information leaflet, and contact numbers for the named paediatrician who will provide support and follow up meetings to discuss the post-mortem examination findings, including contact number for named/SUDI paediatrician. If necessary make contact with parents and explain again the need for a post-mortem examination and the provisional report that is likely to be issued
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4. The first 14 days post SUDI
   Procurator Fiscal investigation
   1. History and Examination report to Procurator Fiscal »
      Completed in the Emergency Department with parents, some questions may need to be followed up with staff/HV/GP once parents have left the Emergency Department
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   2. Procurator Fiscal instructs a post-mortem examination »
      Will be performed by a paediatric pathologist, police will be informed by Procurator Fiscal if they are required to be present
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   3. Area Procurator Fiscal notifies SUDI paediatrician »
      The SUDI paediatrician may not be directly following up the case if not involved from the start but will have an overseeing role in all cases in their health board
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      1. SUDI paediatrician contacts Procurator Fiscal »
         A letter/email is sent requesting a copy of the post-mortem examination results when available
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   4. Area Procurator Fiscal informs parents of SUDI review meeting »
      Also informs parents that Healthcare Improvement Scotland will be co-ordinating the meeting. The Procurator Fiscal also reiterates the support provided by identified paediatrician (may be SUDI paediatrician
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      1. Area Procurator Fiscal sends parent's details to the Scottish Cot Death Trust (SCDT).
         1. SCDT offers support to family »
            Contact is made via a letter offering support
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5. Paediatric pathology instructed by Procurator Fiscal to perform a post-mortem examination
   1. Paediatric pathologist & identified paediatrician* have dialogue before post mortem »
      This discussion ensures that the paediatric pathologist has the required background information surrounding the circumstances of the SUDI and is aware of investigations performed in the Emergency Department
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   2. Initial post-mortem examination report to Procurator Fiscal »
      Preliminary report, final report awaits results from samples taken
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   3. Paediatric pathologist notify Healthcare Improvement Scotland via card return »
      Post card notifications to be placed in each paediatric pathology department so that Healthcare Improvement Scotland can be informed via section of card returned after each post mortem carried out for SUDI. The section which the pathology department keep acts as a prompt to keep the case notes to hand for future SUDI review meeting.
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      1. Healthcare Improvement Scotland contacts SUDI paediatrician »
         This step is done via email followed up with a letter containing infant's details in the event that either the Emergency Department or Procurator Fiscal have failed to make contact, The SUDI paediatrician may identify another paediatrician (if not themselves) to follow up the case including attending a possible SUDI review meeting, and to support the family.
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   4. Pathologist & identified paediatrician to have dialogue after post-mortem examination »
      This is done prior to the 1-2 week parent meeting to enquire if any likely delays in the final report being issued, due to scheduled leave etc.
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6. Follow up parent meetings
   1. 1-2 weeks post SUDI
      Parent meeting »
      Meeting between parents & identified paediatrician & perhaps paediatric pathologist to explain initial post-mortem examination findings and ongoing tests. Explain the SUDI review meeting again if appropriate after post-mortem findings. Medical causes of death diagnosed at initial post-mortem may not require a SUDI review if no others factors present which may require additional support for parents.
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   2. 6-8 weeks post SUDI
      Contact made with parents at 6-8 weeks »
      Identified paediatrician to contact family to reassure that the final post mortem result will be available as soon as all further pathology investigations are completed.
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7. 16+ weeks post SUDI
   Final post-mortem examination report available »
   Results from samples may take several weeks, in particular neuropathology. Once these results are available, a final post-mortem report will be issued by the paediatric pathologist assigned to the case
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   1. Final post-mortem report to Procurator Fiscal »
      The final report will be sent to the Procurator Fiscal by the pathologist.
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      1. Copy of post-mortem examination report sent to SUDI paediatrician »
         The area Procurator Fiscal will forward on a copy of the final post-mortem examination report to the SUDI paediatrician who will ensure identified paediatrician (if not themselves) is aware of the final report.
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      2. Copy of post-mortem examination report sent to GP »
         The area Procurator Fiscal will forward on a copy of the final post-mortem examination report to the GP if it has been requested.
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   2. Healthcare Improvement Scotland authorised to co-ordinate SUDI review via card return »
      Area Procurator Fiscal authorises Healthcare Improvement Scotland to co-ordinate SUDI review via card return.Card return notifications to be placed in each local Deaths Office.
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   3. SUDI review not authorised »
      In any cases where Significant Case Review or fatal accident enquiry or prosecution taking place.
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8. SUDI review meeting
   NHS Board co-ordinate SUDI review meeting »
   Healthcare Improvement Scotland will supply contact details for relevant professionals.
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   1. NHS Board contacts professionals involved »
      Identified paediatrician, paediatric pathologist, GP, health visitor or equivalent, community midwife, social worker. Also consider contacting the community nurse manager. In the case of an in hospital SUDI or SUPC where the infant subsequently dies the professionals involved may be the obstetrician, midwife and the nursing team. Contact is made to arrange a suitable time to meet for all those involved.
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   2. SUDI review meeting arranged »
      SUDI review multi disciplinary meeting arranged to take place by six weeks after final post mortem report is available. This time lag should allow professionals involved to arrange adequate cover to allow them to attend the meeting.
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      1. SUDI review meeting »
         In either hospital with SUDI paediatrician or named paediatrician (if involved with family from start) arranging a meeting room, or in GP surgery meeting room, depending on local agreement. For the in hospital SUDI/SUPC the meeting would most likely take place in the hospital but shall be agreed locally.
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      2. SUDI review summary sheet completed at the meeting »
         Agreement from all on final cause of death and any factors that need to be considered. Any identified additional support for the family are agreed as are the action plan to implement this support.
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      3. 1-2 weeks post SUDI review meeting
         Outcome of SUDI review summary sheet added to:
         Mother's Primary Care records
         Father's Primary Care records
         Maternity records »
         Ensures appropriate care of next infant and that support is available when required at future appointments.
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         Completed review forms and professional feedback forms returned to Healthcare Improvement Scotland for national collation »
         Completed review forms and professional feedback forms returned to Healthcare Improvement Scotland for national collation.
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9. Meeting with family to discuss outcome of SUDI review »
   Identified paediatrician and sometimes the pathologist should meet with the parents to feedback on the outcome of the SUDI Review meeting, in particular informing them of any additional support needs identified. The GP may also be part of this meeting as per local agreement. In particular care of next infant should be discussed and the additional support that will be available, such as the loan of an apnoea monitor.
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   1. Parent notification of records held »
      The identified paediatrician or GP (agreed locally) should inform the parents where the outcome summary of the SUDI review meeting.
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