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"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 authorities.

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 murder."

Most parents view the immediate involvement of the police after their child's death as an intrusion into their grief that also implies guilt.
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 responsible'."

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 hours.
• 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 associations.
• 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 parents.
• 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 ambulance.

"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 dead.

"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 family.

"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 you.

"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."