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A compulsory multi-agency protocol for investigating sudden unexpected death in infancy has been recommended by the expert group set up to look at the issue.

Staff involved should keep an open mind, “knowing that some deaths will be a consequence of neglect or abuse but recognising that the majority are natural tragedies”, says the report. Agencies have a duty of care to parents as well as to the child who has died, it says.

The bereaved family should be visited at home by a paediatrician and specially trained senior police officer within 24 hours of the death. This home visit is “at the heart of the protocol and is not a negotiable element”.

A post mortem examination should be carried out by a paediatric pathologist, and as soon as the results are available a multi-disciplinary meeting should be planned to agree the cause of death and plan future care. A report of this meeting should be sent to the coroner.

In the introduction to the report, the chair of the working group, Baroness Helena Kennedy QC, states that the courts should not be used by doctors to push a theory. Expert witnesses should have recent clinical experience, peer reviewed research and should not roam outside of their area of expertise.

“Doctors should be willing to say “I don’t know” without shame or inhibition”, she says.

The working group, set up by the Royal College of Pathologists and the Royal College of Paediatrics and Child Health, recommends that the protocol is implemented in full, on a mandatory basis, as soon as appropriate staff training has been completed.