When a child dies suddenly and unexpectedly, we, as professionals, have a wide range of duties and obligations that must be fulfilled. Statutory requirements may place constraints on what we can do, when we need to do it, and how we can go about it. At the heart of it all, however, there remains a bereaved family, for whom the worst thing imaginable has just happened. As one bereaved mother put it: “Words may hurt me or make me angry, but I have lost my child, so don’t flatter yourself — nothing that you say will actually make the situation worse”.
Nevertheless, as the quotes at the start of this chapter highlight, parents’ experiences following the death of their child vary enormously, and the way we respond to them can make a considerable difference. The way we respond can make a difference also to the outcome of an investigation. Identifying an unusual medical cause of death, or uncovering the circumstances of a tragic accident or a case of intentional filicide is more likely with a thorough, systematic investigation, conducted with sensitivity and respect, than with one carried out carelessly or in a haphazard or aggressive manner.
In most jurisdictions, the sudden unexpected death of an infant or child requires the case to be referred to a coroner, medical examiner, or procurator fiscal. In England, for example, a coroner is obliged to conduct an investigation into violent or unnatural deaths, deaths where the cause is unknown, and deaths which occur in custody or otherwise in state detention (1). Coroner’s officers, or police officers acting on behalf of the coroner, will need to carry out an investigation into the causes and circumstances of the death. Where there are concerns about parenting, or the possibility of abuse or neglect, there may be other children in the family who need protection, necessitating the involvement of children’s social care services.
Nevertheless, the reality is that in the majority of cases the child’s death will be from natural causes, whether or not we are able to ascertain the actual cause. Therefore, health practitioners will need to carry out full investigations to look for possible medical causes, including infectious or genetic causes, which may have wider implications for the family or community. While infant mortality has fallen dramatically over the past decades, and continues to fall across the world, every death should still be seen as a tragedy, and we should do all we can to further reduce mortality rates and to reduce the risks of future child deaths. In order to do this effectively, we need to learn lessons — from each individual child’s death, and from the patterns of children’s deaths in any area — to identify potentially modifiable factors, and to take effective action to improve childcare, health and welfare services, and support for families. Through all this, all professionals will need to respond sensitively to the family in those awful, early stages of grief — in coming to terms with the reality of their child’s death, in coping with the practical arrangements that need to be made, in breaking the news to family and friends.
Bearing in mind these varying and, at times, potentially conflicting obligations, five primary aims of our response to unexpected infant deaths can be defined (2, 3):
to establish, as far as is possible, the cause or causes of the infant’s death
to identify any potential contributory or modifiable factors
to provide ongoing support to the family
to ensure that all statutory obligations are met
to learn lessons, in order to reduce the risks of future infant deaths.
Underpinning this are three fundamental principles of practice which support a positive response: a thorough, systematic approach to investigation, a sensitive approach to supporting families, and an attitude of collaboration and learning (Figure 5.1).
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