“Our daughter died at the end of October 2000. In January 2001,
on a bright sunny Saturday morning when I was feeling cheerful for
the first time that winter, we received a plain envelope in the
post that contained our daughter’s post-mortem report. There was a
compliment slip attached.”
Shocking though this mother’s story is, it is not unique. Seven
babies die in the UK of sudden unexpected death in infancy (Sudi)
each week. In the aftermath, many parents – devastated and confused
by their child’s death – are dealt with sensitively by
highly-skilled professionals. Others are less fortunate.
Now there are developments to ensure all parents who lose a
child to Sudi receive the same quality of care and treatment by the
In September 2004, a report by Baroness Helena Kennedy QC was
published recommending a national multi-agency protocol for dealing
with Sudi cases, covering how they are investigated through to the
role of the expert witness in court cases (see box). Her report was
the result of a working party set up by the Royal College of
Pathologists and Royal College of Paediatrics and Child Health in
response to the acquittal of Sally Clark in January 2003.
For many, including the Foundation for the Study of Infant
Deaths, changes are long overdue.
Leading the way, the Metropolitan Police has set up a specialist
unit within its Child Abuse Investigation Command, known as Project
Indigo, to investigate cot deaths.
Head of the unit, detective superintendent Alastair Jeffrey,
says the 26 detective inspectors and 60 detective sergeants working
for him receive a day’s training in Sudi.
“The problem with the way we used to do things was that
uniformed officers from local forces would deal with these cases.
They had no training and they may only have dealt with a single
Sudi case in a 30-year career.
“Because they were not experts they were unaware of the signs.
There may be blood around when you are dealing with a Sudi case,
but they could look at that and think they were dealing with a
Most parents view the immediate involvement of the police after
their child’s death as an intrusion into their grief that also
Spotting the signs at a death scene and interpreting what can at
first appear to be a murder confession by parents in the confusion
and distress following a baby’s death is an essential part of the
training. “When she opened the door she told the police ‘I’ve
killed my child’,” says Jeffrey, describing one mother’s experience
included in the police training. “She hadn’t. What she meant was
‘I’m an adult and I couldn’t protect my child so I’m
Just over a month after it was launched, it is too early to tell
how the unit has improved handling of cases in the capital. It has
dealt with 10 cases to date and some issues that need to be tackled
are already emerging. Among them is the need for police officers to
carry out an examination of the child’s body at the scene as well
as the paediatrician. Following the over-reliance on medical
diagnoses in cases such as the death of Victoria Climbie, police
are now expected not to rely solely on medical opinion.
But, says Jeffrey, it is traumatic for the officers involved and
there are practical problems in arranging the time to carry out
these joint examinations with paediatricians – particularly within
the 24-hour target recommended by Kennedy.
Jeffrey believes the Department of Health should make compliance
compulsory for health trusts. But Martin Ward Platt, consultant
paediatrician at the Royal Victoria Infirmary in Newcastle upon
Tyne, says he has not met many paediatricians who believe the
proposal is workable.
“There is an assumption in the Kennedy report that
paediatricians can make reasonable death scene investigations and
make a competent assessment,” Ward Platt explains.
“In my view it is the police who are the real experts in
investigating a death scene and there are probably only three
paediatricians in the country who can do that. The rest of us will
never develop the expertise because we will not do it enough.”
Catherine Lee, London regional co-ordinator with the Foundation
for the Study of Infant Deaths, backs the proposal for the joint
home visit within 24 hours, but says the fragmentation of the
health service presents problems. “Since the early 1990s, Sudi
cases have dropped around 75%, so it would not be sensible to
designate one consultant paediatrician in every trust because there
are not enough cases,” Lee warns.
Elsewhere in the system other problems implementing Kennedy’s
recommendations are inevitable.
The role played by the paediatric pathologist is vital to
parents who are desperate to know – and quickly – why their baby
died. But vacancy rates in paediatric pathology are running at a
staggering 25%, which means there are just 40 in post in England
and Wales. There is just one paediatric forensic pathologist.
Royal College of Pathologists president James Underwood says
that when hospitals advertise to fill a post often nobody applies.
He cites damage inflicted on the reputation of paediatric pathology
by the scandals involving organ stripping at the Bristol Royal
Infirmary and Alder Hey children’s hospital in Liverpool as one
reason for this.
Money has been channelled by the DoH into trying to boost
numbers, but Underwood insists the reforms recommended in the
Kennedy report “absolutely cannot work” without extra paediatric
pathologists and that making the protocol compulsory immediately
would be pointless.
Despite this absence of a compulsory protocol, there are reasons
to be optimistic. Local children’s safeguarding boards included in
the Children Act 2004 will be expected to have multi-agency child
death review teams, whose job it will be to look at every child
death within its area.
Andrew Webb, who is social services director at Stockport
Council and was involved in the working party set up after Clark’s
acquittal, says their work was well-timed because it coincided with
the government’s Every Child Matters agenda.
“We felt like we were pushing against an open door,” Webb says.
“The time seemed right not just to challenge professionals but also
to have a sharp prod at government policy.”
Baroness Kennedy’s recommendations
- The creation of a compulsory national protocol.
- A police officer and Sudi paediatrician to visit the home and
talk to parents who have lost a child to Sudi, preferably within 24
- An initial strategy meeting to be held by the lead
professionals to agree their approach.
- Judges to establish the credentials of any expert witness
before they can give evidence.
- Expert witnesses to be accredited by the Royal Colleges or
- Coroners to order a post-mortem to be carried out by a
paediatric pathologist, preferably within 48 hours.
- Coroners to make a copy of the report available to the Sudi
paediatrician and give permission for it to be discussed with
- Police officers to have special training in Sudi.
- Sudi paediatricians to advise strategic health authorities on
the commissioning of services relevant to Sudi.
- Sudi paediatricians to ensure all multi-agency strategy
discussions take place.
‘When I woke, he wasn’t breathing’
Karen Mazur’s son Kieron died in August 2000, two months after
he was born. She and her family were staying in a hotel to
celebrate her mother’s 50th birthday when the baby died.
“When I woke up in the morning Kieron wasn’t breathing.
“The first thing I did was call my mum. She met my cousins, who
are nurses, in the hallway and when I opened the door they were
there. My cousin tried to resuscitate him as we called an
“I went to the hospital and my family stayed at the hotel. They
were interviewed by police officers from two forces because the
hotel was on the border of two counties and they were not allowed
to leave the room until both lots of questioning had taken place.
Both were unaware during this time whether Kieron was alive or
“The CID arrived at the hospital and interviewed me. They were
very sensitive and explained they were there as a formality. At
this point, Stephen Foote, a family liaison officer who had been
given to us to ‘start the investigation on a better foot’, came to
the hospital. We could not have coped without him. He dealt with
all the official aspects while offering us invaluable support as a
“We had to wait three weeks to bury Kieron due to the
post-mortem -Êcarried out by a paediatric pathologist.
“There were many other things to deal with after Kieron’s death:
his detailed post-mortem report being sent firstly to the wrong
address and then arriving through my letterbox with no explanation;
his death certificate arriving crumpled in the post; a phone call
from the coroner’s office a year to the day of his death asking if
I wanted the baby grow he had been wearing the night he died.
“The death of your baby rocks the foundations of your soul and I
was aware these things needed to be dealt with, as I am aware that
when a perfectly healthy baby goes to sleep and does not wake up it
is bound to create suspicion. But it is only when the baby is your
baby you can understand the devastating affect their death has on
“The smallest amount of thought and consideration can make a
huge difference to the way people pick up the pieces of their
lives, long after the paperwork has been filed away.”