New guidelines on management of sudden unexpected death in infancy and childhood in children

Guideline Launch    nisar-qa

New guidelines on management of sudden unexpected death in infancy and childhood in children launched

House of Lords, Westminster, Committee Room G, London

Wednesday 30 November 2016

The Parliamentary Members in attendance:

  • Baroness Helena Kennedy (Chair of the Working Party)
  • Lord Hunt of King’s Heath (Labour)
  • Baroness Masham of Ilton (Crossbench)
  • Baroness Ilora Finlay (Crossbench)
  • Antoinette Sandbach MP (Conservative)
  • Justin Madders MP (Labour)
  • Liz Saville Roberts MP (Plaid Cymru)


Sudden unexpected death in infancy and childhood (2nd edition 2016) Multi-agency guidelines for care and investigation.

The guidelines have been published by a multi-agency working group convened by The Royal College of Pathologists (RCPath) and The Royal College of Paediatrics and Child Health. They aim to be sensitive to the needs of grief-stricken parents while also enabling an explanation to be found. They also make recommendations to each profession and outline best practice for each part of the investigation process.  and encompasses the statutory duties of individual professionals and agencies to investigate all sudden and unexpected deaths in infancy and childhood according to Working Together to Safeguard Children: A Guide to Inter-agency Working to Safeguard and Promote the Welfare of Children (Department for Education, 2015) and best evidence. Such guidance is based around regulatory structures in England, but it is intended that the principles of the guidelines can also be applied in areas in which other systems are in place.

The original guidelines published in in 2004 took in evidence from over 30 key organisations and representatives in child health and protection and followed high profile cases of miscarriages of justice involving the prosecution of mothers for causing the deaths of their babies. These events raised serious concerns about the role of the expert witness in court, issues about standards of proof, quality of evidence and about the procedures adopted for the investigation of sudden unexpected deaths of infants.

This 2016 edition of the guidelines have been extensively reviewed and updated by an expert working group from the healthcare, charity and justice sectors and cover multi-agency planning, supporting families, assessment of the environment and circumstances of the death, case discussion, the post-mortem and the inquest and role of the coroner. They are based on the best current international research.

The working group also recognises that further work is needed in the area of investigating sudden death in infancy and childhood and hope that this document will stimulate discussion and further research.



Dr Suzy Lishman, President, The Royal College of Pathologists:  Welcome and opening remarks

Baroness Helena Kennedy as Chair of the Working Group

Baroness Kennedy highlighted the importance careful protocols in investigating the sudden deaths of infants and children. Not only do sensitive procedures help with the high emotions involved in such cases, they also protect the human rights of all involved – from the deceased child to the family members but also the professionals who are involved. Proper investigation means good record keeping and the preservation of evidence as well as vigilance to ensure that any further inquiries are not hampered by early mistakes. The pursuit of just outcomes has been our guiding principle.


Professor Neil Sebire, lead author and Chair, The Royal College of Pathologists’ Specialty Advisory Committee on Prenatal, Perinatal and Paediatric Pathology

  • The multidisciplinary approach and how this has worked
  • The relative lack of high quality evidence in this area
  • The fact that most cases remain unexplained and the need far more research


Dr Nisar A Mir, Chair National Network of Child Death Overview Panels (NNCDOP) & Fellow Royal College of Paediatrics & Child Health

  • Although there have been significant reductions in child deaths in the past three decades, too many children are still dying unnecessarily; England, Wales and Scotland saw 4760 infants, children and adolescents die before their 18th birthday in 2014.
  • In 2008, local Child Death Overview Panels (CDOPs) were statutorily established in England, with the responsibility of reviewing the deaths of all children under 18, their main function is to prevent future child deaths. Currently there are 92 such panels and during 2015 the panels reviewed 3665 child deaths.
  • One in five deaths is avoidable and other modifiable factors are present in one third of the cases; multiple risk factors were present in 60% of children where the death was sudden and unexpected and occurred and/or was associated with abuse or neglect.
  • If the UK had the same childhood mortality for children as Sweden, there would be five fewer child deaths every day.
  • There is an urgent need for the development of strategies for prevention of avoidable child deaths across the country.


Francine Bates CEO The Lullaby Trust UK

  • Shocking Impact of sudden infant death on parents  who are often traumatised
  • Recognition that process of investigation can take many months up to the PM report and Inquest and importance of communication with parents during that time
  • Need for sensitive and on-going  support over and beyond final conclusions of coroner
  • The value of sensitive and caring support by professionals in all agencies cannot be overstated to support families through the bereavement process – which may take years.


Audience Q&A session

The panel for the audience Q&A session comprised the main speakers who were   joined by some of the members of the working group to form a multi-agency panel as follows:

  • His Honour, Peter Thornton QC, (former Chief Coroner)
  • Dr Peter Sidebotham, Associate Professor of Child Health, Warwick Medical School
  • Detective Superintendent Geoff Wessell, Chair, National Policing Child Death Investigation Group, Avon & Somerset Constabulary


Guidelines (PDF):

The Investigation of Sudden Unexpected Death in Infancy and Childhood

Multi-agency guidelines for care and investigation

Chair: The Baroness Helena Kennedy QC
Second Edition, November 2016