- Email: [email protected]
Cot death: the responsibilities of the paediatrician
Current Paediatrics (2000) 10, 92–95 © 2000 Harcourt Publishers Ltd doi: 10.1054/ cupe.2000.0093, available online at http://www.idealibrary.com on
Serial: Cot death
Cot death: the responsibilities of the paediatrician
C. J. Bacon
KEY POINTS
•
1. A paediatrician should be designated in each area to take on responsibility for dealing with cot deaths. 2. The main objectives are to investigate the cause of the death and to ensure proper support for the family. 3. Tasks include a home visit soon after the death, briefing of the pathologist, and holding a case discussion as soon as all details are available. 4. A balance is needed between medical and forensic investigation, so it is essential to work in cooperation with police and coroner.
•
• •
INTRODUCTION
Paediatricians are best equipped to undertake the difficult and complex task of identifying the many possible causes of sudden infant death. Paediatricians have a responsibility to safeguard other children in the family, including those yet unborn, when unexpected death has arisen from inherited disease, such as a disorder of metabolism, or from covert maltreatment. Paediatricians are experienced in ensuring that bereaved families receive all the support that they need, both immediately and when the next baby is born. The greatest reduction in post-neonatal infant mortality in recent years has resulted from research led by paediatricians into risk factors for sudden infant death syndrome (SIDS). Further reductions should now be achievable.
Of course not everyone will have an interest in cot death or the time to pursue it. However it seems reasonable to expect that in each Trust one person, who will often be a general or a community paediatrician, should be designated to take on special responsibility for cot death. This person will need to have a foot both in the hospital and in the community camps: this may be more difficult in those areas where hospital and community paediatrics are sundered into separate Trusts, but should still be possible given good professional cooperation. There is something to be said for combining responsibilities for cot death and for child protection.
In 1985 the British Paediatric Association (BPA) and the Foundation for the Study of Infant Deaths (FSID) recommended that a paediatrician should be designated in each health district to have responsibility for all aspects of cot death. In some places this scheme has worked well, but in many others it never really got started or has fallen into abeyance, and families report very variable experience of the support they receive from paediatricians.1 Some paediatricians argue that they have more than enough to do dealing with children who are sick, and that dealing with babies who have died unexpectedly at home is not their concern. However I would maintain that cot death is very much part of a paediatrician’s business, on several counts:
NUMBERS INVOLVED The role has become more feasible now that the number of cot deaths in England and Wales has fallen to around 400 a year. For the purposes of this paper ‘cot death’ is taken to mean all sudden unexpected deaths in infancy, both the minority for which a cause is
C. J. Bacon, Retired Consultant Paediatrician, Glebe House, Danby Wiske, Northallerton, North Yorkshire DL7 0LY, UK 92
Cot death found, and the majority that remain unexplained and are classified as SIDS or as ‘unascertained’. In 1998, the latest year for which figures are available, the Office for National Statistics recorded 295 deaths registered as SIDS and 46 as unascertained. This means that even the larger Trusts are unlikely to have more than six cot deaths a year, so that the workload for designated paediatricians should not be excessive. On the other hand, by definition the work will be unpredictable and will demand immediate attention, so that routine duties will have to be shelved or delegated at short notice. This will require colleagues to accept that this task merits the same over-riding priority as do other unforeseeable paediatric emergencies. Smaller Trusts might combine to share the same team. Cover arrangements would be needed for sickness and holidays.
2.
3.
RESPONSE TO COT DEATH Recommendations about the response to cot death were given in the recent report on the study of sudden unexpected deaths in infancy (SUDI) carried out between 1993 and 1996 as part of the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI).2 This study was the largest and most comprehensive of its kind yet undertaken in the UK, and its recommendations largely correspond with those from other parts of the world. The first seven of the points below are based on the SUDI report. There are two main requirements in the aftermath of a cot death: the need to investigate the cause of death, and the need to support the family. These requirements are of equal importance and must be pursued in parallel, neither being overemphasized to the detriment of the other. Combining the two may at times seem uncomfortable, but families will accept the need for full investigation—and indeed will usually welcome it—so long as they are given enough explanation and support.
ROLE OF THE PAEDIATRICIAN To meet these requirements the designated paediatrician will need to take the following steps: 1.
Set up a notification system that will inform him/her of any unexpected infant death in his area in less than 48 h. This system could be built on the network that is already in place for the purposes of the CESDI rapid report scheme, and could be run by the CESDI district coordinator. It will need to tap all sources that might first learn of the unexpected death of a baby, such as general practitioners, health visitors, the ambulance service, accident departments, paediatricians,
4.
5.
93
mortuary attendants, pathologists and coroner’s officers. Ensure that the accident departments to which cot death victims may be taken are properly versed in how to manage the situation and in particular in how to cope with the family (FSID has produced a very helpful leaflet for this purpose). Sometimes a death is certified at home and the body is taken straight to a mortuary rather than to a hospital. It will then be more difficult for the paediatrician to become immediately involved and to provide early support. If this is a frequent problem it may be necessary to try and persuade general practitioners of the advantages of always sending cot death victims to the hospital. Arrange to visit the home of the bereaved family as soon as possible after the death, preferably within 48 h, for the purpose of gathering information and initiating support. Experience in the SUDI studies showed that families welcome such an early visit, and that the traditional practice of waiting till later is mistaken. A home visit is far more acceptable than a consultation in the accident department or the paediatric clinic, which most families find alien, rushed and unrelaxed. The designated paediatrician need not necessarily make this home visit himself; it might be made, under his direction, by a specially trained health visitor or community paediatric nurse. Although it might seem simplest for the family’s usual health visitor to do it, this extremely difficult task requires special training and experience. It is helpful if the family’s health visitor can make the introduction. A checklist will be needed to ensure that all relevant information is gathered, but the family must be allowed time to tell the story in their own way and at their own pace, and to ask the questions that are teeming in their minds. All this will take at least an hour, sometimes much longer. Before he leaves the paediatrician (or specialist nurse) must ensure that the family is put in touch with people who can support them, for example through the FSID’s network of befrienders. Assemble all relevant records about the baby and the family. These will include maternity, paediatric and accident department notes, as well as any records from the general practitioner and the health visitor, and sometimes from the social services. The child protection register should also be consulted. Compile, from the information obtained at the home visit and from the previous records, a full briefing for the pathologist who is instructed for the post-mortem. Pathologists
94
Current Paediatrics
6.
7.
8.
9.
10.
will tell you that the single most helpful item in elucidating the cause of an unexpected infant death is a good history. This report must be produced very rapidly; it may sometimes be better to delay the post-mortem for 24–48 h to ensure that it is complete. Liaison between the designated paediatrician and the pathologist is invaluable; there should be no problems here when the local paediatric pathologist is involved, but there may be more difficulty when a forensic specialist is called in. Attend the post-mortem examination. Direct discussion with the pathologist may throw up new ideas about the death and promotes future liaison. It might also help ensure that the most suitable pathologist does the post-mortem and that he follows the recommended protocol. Organize and chair a case discussion as soon as all the results of pathology investigations are available, which will usually be about a month after the death. Participants should always include the general practitioner, the health visitor and the pathologist, and sometimes other professionals such as a midwife or social worker. Attendance by the primary care team is essential, so the meeting should be held at a time and place that best suits them. The agenda should include all the antecedents and circumstances of the death, possible causes and contributory factors, lessons for professionals and for carers, and support for the family, both in their present bereavement and for when they have another baby. Sometimes the complete picture of a death only becomes clear when all those who know the family have met to join up their pieces of the jigsaw. Cooperate with the police and coroner throughout. Because this is an important and contentious issue it is discussed at greater length below. Oversee the implementation of the CONI (Care of the Next Infant) scheme within his area. Participate in collaborative studies of cot death. Following the reduction in incidence, research can yield meaningful results only if data are aggregated.
COOPERATION WITH THE POLICE Now that cot deaths are fewer, concerns about the proportion that result from maltreatment have come to the fore.3 It is impossible to be certain how large this proportion is, but the best estimate is likely to come from large-scale studies that are populationbased and consider this question systematically. The
SUDI studies, which meet these criteria, suggest that the figure is about 10%.2 Anxiety is heightened by the evidence that parents who kill one baby may go on to harm another if they are not identified.4 Because of these concerns, in some parts of the country the police and forensic pathologists are taking over the investigation of all sudden infant deaths, natural and unnatural alike. Such a predominantly forensic approach brings the serious risk that causes of natural deaths, which still constitute the large majority, may not be adequately explored, and that families may be treated inappropriately. Paediatricians are in the best position to ensure that the medical and humanitarian aspects of cot death are given sufficient emphasis, that there is a proper balance between forensic and medical investigation, and that the families receive appropriate advice and support. However they will only be able to achieve these goals if they cooperate with police and coroners. If they try to work independently they will provoke antagonism and be ignored. The influence of police and coroners in this area far outweighs that of doctors, and recently the mass media have followed the professional press in calling for more thorough investigation. Paediatricians will be swept aside if they attempt to stand against this popular tide: they will do better to try and ensure that its flow is properly controlled. This means that at every stage they must work with the police and coroner. Such liaison may seem an uncomfortable and perhaps inappropriate role for a doctor—though the procedures for child protection provide a precedent that is now well accepted. Preliminary discussions with the General Medical Council and with the Medical Defence Union suggest that there would be no ethical objection if the doctor is acting with the coroner’s authority, and if his cooperation with the police is made clear to the parents from the outset. The parents could then choose not to talk to him, but experience suggests that this would not happen often. The exact form that this cooperation takes will vary from place to place, since neither coroners nor police forces follow central direction but make individual arrangements within their patch. The designated paediatrician will need to introduce himself to the coroners in his area and to the senior police officers responsible for the investigation of infant deaths. Following recent publicity several police forces are now devising new procedures, and paediatricians may need to move fast to influence their shape before they become established. In some areas, for example, it is proposed that the home visit and collection of information after any cot death should be done entirely by police officers, with no input from a health professional. Since most cot deaths result from natural causes this cannot be appropriate. A joint approach is clearly more suitable, and senior police officers have proved receptive to approaches from doctors who are willing to cooperate in creating a balance between
Cot death medical and forensic aspects. Some police forces are arranging for the investigation of cot deaths to be carried out by officers from their child protection or family liaison units, who are more experienced in dealing with sensitive issues involving families and in working jointly with other agencies. This seems a helpful development. Indeed a case could be made for dealing with unexpected infant deaths by a mechanism similar to that used for child protection, which would ensure that every death was subject to a thorough multiagency investigation. It is interesting that FSID, widely regarded as the champion of bereaved parents, is now campaigning for better investigation of all cot deaths, which would then be categorized as SIDS only after the most thorough scrutiny. It is thought that this would be acceptable to parents if the reasons were explained, and that it would help remove the stigma that has become attached to the term SIDS following recent high-profile cases. Ideally the designated paediatrician would build a relationship with his opposite number in the police that ensured cooperation and consultation at every stage. They could, for example, make the home visit together; or if they visited separately they should confer about the information obtained and its interpretation. Similarly they should cooperate in the collation and interpretation of the medical records, and in the provision of the report to the pathologist. Paediatric participation from the outset should help to head off misguided police action after a death that the paediatrician could readily identify as natural, and to ensure that the family was always treated and supported in an appropriate manner. On the other hand the paediatrician must accept that the police have a responsibility to investigate any death that might be unnatural, and that the distinction between natural and unnatural often cannot be made for some time—sometimes never. This dilemma calls for extraordinary skill and sensitivity on the part of everyone involved. There might be advantages if a police officer routinely attended the subsequent case discussion; it would follow the precedent of child protection, and would help to build mutual experience and trust.
95
pendence. It is therefore sensible for the designated paediatrician to go and meet the coroners in his area and discuss how they would like cot deaths to be handled. Some coroners may need to be persuaded of the advantages of a joint investigation by health and police. Others may need no persuasion, and may wish to be kept informed at all stages, receiving a copy of the paediatrician’s initial assessment in addition to the report of the pathologist, and even perhaps chairing the case discussion. Doctors might feel more comfortable in cooperating with the police if they knew they had the coroner’s approval. It is the coroner who chooses the pathologist, and the paediatrician may need to remind him tactfully of the advantages, as spelt out in the SUDI report,2 of instructing a paediatric pathologist for cot deaths. Unfortunately there are not yet enough of them to do all the cot death autopsies throughout the country, but undoubtedly they could do more if coroners were so persuaded and referrals to specialist centres were more frequent. If a general or forensic pathologist has to be chosen, it should be one who has had at least some paediatric training. RESOURCES AND PRIORITIES There seems no immediate prospect that extra money will be forthcoming to fund the role of designated paediatrician. However people in many parts of the country are doing the work already, regarding it as one of their more important responsibilities. Ultimately it is a question of priorities. Perhaps the Royal College of Paediatrics and Child Health, and the British Association of Community Child Health, might here pick up the lead once taken by the BPA. Meanwhile I hope this paper may encourage individuals working in an area where there is no designated paediatrician to consider taking on the task. They would find it as interesting, varied and rewarding as anything else they do. Above all, failure by paediatricians to become involved will do families a great disservice. REFERENCES
COOPERATION WITH THE CORONER The position of the coroner, who has statutory oversight of the investigation of unexpected death at any age, is crucial. The Coroners’ Society takes a keen and well-informed interest in infant deaths, but the Society, although it may make recommendations, is not in a position to determine the behaviour of individual coroners, who enjoy a large measure of inde-
1. 2. 3. 4.
Dent A, Condon L, Blair P, Fleming P. A study of bereavement care after sudden and unexpected death. Arch Dis Child 1996; 74: 522–6. Fleming P, Blair P, Bacon C, Berry J, eds. Sudden unexpected deaths in infancy; the CESDI SUDI studies 1993–96. Stationery Office, 2000. Meadow R. Unnatural sudden infant death. Arch Dis Child 1999; 80: 7–14. Wolkind S, Taylor EM, Waite AJ, Dalton M, Emery JL. Recurrence of unexpected infant death. Acta Paed 1993; 82: 873–6.
Serial: Cot death
Cot death: the responsibilities of the paediatrician
C. J. Bacon
KEY POINTS
•
1. A paediatrician should be designated in each area to take on responsibility for dealing with cot deaths. 2. The main objectives are to investigate the cause of the death and to ensure proper support for the family. 3. Tasks include a home visit soon after the death, briefing of the pathologist, and holding a case discussion as soon as all details are available. 4. A balance is needed between medical and forensic investigation, so it is essential to work in cooperation with police and coroner.
•
• •
INTRODUCTION
Paediatricians are best equipped to undertake the difficult and complex task of identifying the many possible causes of sudden infant death. Paediatricians have a responsibility to safeguard other children in the family, including those yet unborn, when unexpected death has arisen from inherited disease, such as a disorder of metabolism, or from covert maltreatment. Paediatricians are experienced in ensuring that bereaved families receive all the support that they need, both immediately and when the next baby is born. The greatest reduction in post-neonatal infant mortality in recent years has resulted from research led by paediatricians into risk factors for sudden infant death syndrome (SIDS). Further reductions should now be achievable.
Of course not everyone will have an interest in cot death or the time to pursue it. However it seems reasonable to expect that in each Trust one person, who will often be a general or a community paediatrician, should be designated to take on special responsibility for cot death. This person will need to have a foot both in the hospital and in the community camps: this may be more difficult in those areas where hospital and community paediatrics are sundered into separate Trusts, but should still be possible given good professional cooperation. There is something to be said for combining responsibilities for cot death and for child protection.
In 1985 the British Paediatric Association (BPA) and the Foundation for the Study of Infant Deaths (FSID) recommended that a paediatrician should be designated in each health district to have responsibility for all aspects of cot death. In some places this scheme has worked well, but in many others it never really got started or has fallen into abeyance, and families report very variable experience of the support they receive from paediatricians.1 Some paediatricians argue that they have more than enough to do dealing with children who are sick, and that dealing with babies who have died unexpectedly at home is not their concern. However I would maintain that cot death is very much part of a paediatrician’s business, on several counts:
NUMBERS INVOLVED The role has become more feasible now that the number of cot deaths in England and Wales has fallen to around 400 a year. For the purposes of this paper ‘cot death’ is taken to mean all sudden unexpected deaths in infancy, both the minority for which a cause is
C. J. Bacon, Retired Consultant Paediatrician, Glebe House, Danby Wiske, Northallerton, North Yorkshire DL7 0LY, UK 92
Cot death found, and the majority that remain unexplained and are classified as SIDS or as ‘unascertained’. In 1998, the latest year for which figures are available, the Office for National Statistics recorded 295 deaths registered as SIDS and 46 as unascertained. This means that even the larger Trusts are unlikely to have more than six cot deaths a year, so that the workload for designated paediatricians should not be excessive. On the other hand, by definition the work will be unpredictable and will demand immediate attention, so that routine duties will have to be shelved or delegated at short notice. This will require colleagues to accept that this task merits the same over-riding priority as do other unforeseeable paediatric emergencies. Smaller Trusts might combine to share the same team. Cover arrangements would be needed for sickness and holidays.
2.
3.
RESPONSE TO COT DEATH Recommendations about the response to cot death were given in the recent report on the study of sudden unexpected deaths in infancy (SUDI) carried out between 1993 and 1996 as part of the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI).2 This study was the largest and most comprehensive of its kind yet undertaken in the UK, and its recommendations largely correspond with those from other parts of the world. The first seven of the points below are based on the SUDI report. There are two main requirements in the aftermath of a cot death: the need to investigate the cause of death, and the need to support the family. These requirements are of equal importance and must be pursued in parallel, neither being overemphasized to the detriment of the other. Combining the two may at times seem uncomfortable, but families will accept the need for full investigation—and indeed will usually welcome it—so long as they are given enough explanation and support.
ROLE OF THE PAEDIATRICIAN To meet these requirements the designated paediatrician will need to take the following steps: 1.
Set up a notification system that will inform him/her of any unexpected infant death in his area in less than 48 h. This system could be built on the network that is already in place for the purposes of the CESDI rapid report scheme, and could be run by the CESDI district coordinator. It will need to tap all sources that might first learn of the unexpected death of a baby, such as general practitioners, health visitors, the ambulance service, accident departments, paediatricians,
4.
5.
93
mortuary attendants, pathologists and coroner’s officers. Ensure that the accident departments to which cot death victims may be taken are properly versed in how to manage the situation and in particular in how to cope with the family (FSID has produced a very helpful leaflet for this purpose). Sometimes a death is certified at home and the body is taken straight to a mortuary rather than to a hospital. It will then be more difficult for the paediatrician to become immediately involved and to provide early support. If this is a frequent problem it may be necessary to try and persuade general practitioners of the advantages of always sending cot death victims to the hospital. Arrange to visit the home of the bereaved family as soon as possible after the death, preferably within 48 h, for the purpose of gathering information and initiating support. Experience in the SUDI studies showed that families welcome such an early visit, and that the traditional practice of waiting till later is mistaken. A home visit is far more acceptable than a consultation in the accident department or the paediatric clinic, which most families find alien, rushed and unrelaxed. The designated paediatrician need not necessarily make this home visit himself; it might be made, under his direction, by a specially trained health visitor or community paediatric nurse. Although it might seem simplest for the family’s usual health visitor to do it, this extremely difficult task requires special training and experience. It is helpful if the family’s health visitor can make the introduction. A checklist will be needed to ensure that all relevant information is gathered, but the family must be allowed time to tell the story in their own way and at their own pace, and to ask the questions that are teeming in their minds. All this will take at least an hour, sometimes much longer. Before he leaves the paediatrician (or specialist nurse) must ensure that the family is put in touch with people who can support them, for example through the FSID’s network of befrienders. Assemble all relevant records about the baby and the family. These will include maternity, paediatric and accident department notes, as well as any records from the general practitioner and the health visitor, and sometimes from the social services. The child protection register should also be consulted. Compile, from the information obtained at the home visit and from the previous records, a full briefing for the pathologist who is instructed for the post-mortem. Pathologists
94
Current Paediatrics
6.
7.
8.
9.
10.
will tell you that the single most helpful item in elucidating the cause of an unexpected infant death is a good history. This report must be produced very rapidly; it may sometimes be better to delay the post-mortem for 24–48 h to ensure that it is complete. Liaison between the designated paediatrician and the pathologist is invaluable; there should be no problems here when the local paediatric pathologist is involved, but there may be more difficulty when a forensic specialist is called in. Attend the post-mortem examination. Direct discussion with the pathologist may throw up new ideas about the death and promotes future liaison. It might also help ensure that the most suitable pathologist does the post-mortem and that he follows the recommended protocol. Organize and chair a case discussion as soon as all the results of pathology investigations are available, which will usually be about a month after the death. Participants should always include the general practitioner, the health visitor and the pathologist, and sometimes other professionals such as a midwife or social worker. Attendance by the primary care team is essential, so the meeting should be held at a time and place that best suits them. The agenda should include all the antecedents and circumstances of the death, possible causes and contributory factors, lessons for professionals and for carers, and support for the family, both in their present bereavement and for when they have another baby. Sometimes the complete picture of a death only becomes clear when all those who know the family have met to join up their pieces of the jigsaw. Cooperate with the police and coroner throughout. Because this is an important and contentious issue it is discussed at greater length below. Oversee the implementation of the CONI (Care of the Next Infant) scheme within his area. Participate in collaborative studies of cot death. Following the reduction in incidence, research can yield meaningful results only if data are aggregated.
COOPERATION WITH THE POLICE Now that cot deaths are fewer, concerns about the proportion that result from maltreatment have come to the fore.3 It is impossible to be certain how large this proportion is, but the best estimate is likely to come from large-scale studies that are populationbased and consider this question systematically. The
SUDI studies, which meet these criteria, suggest that the figure is about 10%.2 Anxiety is heightened by the evidence that parents who kill one baby may go on to harm another if they are not identified.4 Because of these concerns, in some parts of the country the police and forensic pathologists are taking over the investigation of all sudden infant deaths, natural and unnatural alike. Such a predominantly forensic approach brings the serious risk that causes of natural deaths, which still constitute the large majority, may not be adequately explored, and that families may be treated inappropriately. Paediatricians are in the best position to ensure that the medical and humanitarian aspects of cot death are given sufficient emphasis, that there is a proper balance between forensic and medical investigation, and that the families receive appropriate advice and support. However they will only be able to achieve these goals if they cooperate with police and coroners. If they try to work independently they will provoke antagonism and be ignored. The influence of police and coroners in this area far outweighs that of doctors, and recently the mass media have followed the professional press in calling for more thorough investigation. Paediatricians will be swept aside if they attempt to stand against this popular tide: they will do better to try and ensure that its flow is properly controlled. This means that at every stage they must work with the police and coroner. Such liaison may seem an uncomfortable and perhaps inappropriate role for a doctor—though the procedures for child protection provide a precedent that is now well accepted. Preliminary discussions with the General Medical Council and with the Medical Defence Union suggest that there would be no ethical objection if the doctor is acting with the coroner’s authority, and if his cooperation with the police is made clear to the parents from the outset. The parents could then choose not to talk to him, but experience suggests that this would not happen often. The exact form that this cooperation takes will vary from place to place, since neither coroners nor police forces follow central direction but make individual arrangements within their patch. The designated paediatrician will need to introduce himself to the coroners in his area and to the senior police officers responsible for the investigation of infant deaths. Following recent publicity several police forces are now devising new procedures, and paediatricians may need to move fast to influence their shape before they become established. In some areas, for example, it is proposed that the home visit and collection of information after any cot death should be done entirely by police officers, with no input from a health professional. Since most cot deaths result from natural causes this cannot be appropriate. A joint approach is clearly more suitable, and senior police officers have proved receptive to approaches from doctors who are willing to cooperate in creating a balance between
Cot death medical and forensic aspects. Some police forces are arranging for the investigation of cot deaths to be carried out by officers from their child protection or family liaison units, who are more experienced in dealing with sensitive issues involving families and in working jointly with other agencies. This seems a helpful development. Indeed a case could be made for dealing with unexpected infant deaths by a mechanism similar to that used for child protection, which would ensure that every death was subject to a thorough multiagency investigation. It is interesting that FSID, widely regarded as the champion of bereaved parents, is now campaigning for better investigation of all cot deaths, which would then be categorized as SIDS only after the most thorough scrutiny. It is thought that this would be acceptable to parents if the reasons were explained, and that it would help remove the stigma that has become attached to the term SIDS following recent high-profile cases. Ideally the designated paediatrician would build a relationship with his opposite number in the police that ensured cooperation and consultation at every stage. They could, for example, make the home visit together; or if they visited separately they should confer about the information obtained and its interpretation. Similarly they should cooperate in the collation and interpretation of the medical records, and in the provision of the report to the pathologist. Paediatric participation from the outset should help to head off misguided police action after a death that the paediatrician could readily identify as natural, and to ensure that the family was always treated and supported in an appropriate manner. On the other hand the paediatrician must accept that the police have a responsibility to investigate any death that might be unnatural, and that the distinction between natural and unnatural often cannot be made for some time—sometimes never. This dilemma calls for extraordinary skill and sensitivity on the part of everyone involved. There might be advantages if a police officer routinely attended the subsequent case discussion; it would follow the precedent of child protection, and would help to build mutual experience and trust.
95
pendence. It is therefore sensible for the designated paediatrician to go and meet the coroners in his area and discuss how they would like cot deaths to be handled. Some coroners may need to be persuaded of the advantages of a joint investigation by health and police. Others may need no persuasion, and may wish to be kept informed at all stages, receiving a copy of the paediatrician’s initial assessment in addition to the report of the pathologist, and even perhaps chairing the case discussion. Doctors might feel more comfortable in cooperating with the police if they knew they had the coroner’s approval. It is the coroner who chooses the pathologist, and the paediatrician may need to remind him tactfully of the advantages, as spelt out in the SUDI report,2 of instructing a paediatric pathologist for cot deaths. Unfortunately there are not yet enough of them to do all the cot death autopsies throughout the country, but undoubtedly they could do more if coroners were so persuaded and referrals to specialist centres were more frequent. If a general or forensic pathologist has to be chosen, it should be one who has had at least some paediatric training. RESOURCES AND PRIORITIES There seems no immediate prospect that extra money will be forthcoming to fund the role of designated paediatrician. However people in many parts of the country are doing the work already, regarding it as one of their more important responsibilities. Ultimately it is a question of priorities. Perhaps the Royal College of Paediatrics and Child Health, and the British Association of Community Child Health, might here pick up the lead once taken by the BPA. Meanwhile I hope this paper may encourage individuals working in an area where there is no designated paediatrician to consider taking on the task. They would find it as interesting, varied and rewarding as anything else they do. Above all, failure by paediatricians to become involved will do families a great disservice. REFERENCES
COOPERATION WITH THE CORONER The position of the coroner, who has statutory oversight of the investigation of unexpected death at any age, is crucial. The Coroners’ Society takes a keen and well-informed interest in infant deaths, but the Society, although it may make recommendations, is not in a position to determine the behaviour of individual coroners, who enjoy a large measure of inde-
1. 2. 3. 4.
Dent A, Condon L, Blair P, Fleming P. A study of bereavement care after sudden and unexpected death. Arch Dis Child 1996; 74: 522–6. Fleming P, Blair P, Bacon C, Berry J, eds. Sudden unexpected deaths in infancy; the CESDI SUDI studies 1993–96. Stationery Office, 2000. Meadow R. Unnatural sudden infant death. Arch Dis Child 1999; 80: 7–14. Wolkind S, Taylor EM, Waite AJ, Dalton M, Emery JL. Recurrence of unexpected infant death. Acta Paed 1993; 82: 873–6.