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Complex Situations (SLO7)
This was previously featured in an exam
This was previously featured in an exam
Question 52 of 180
Whilst leading the ED shift overnight, you are asked to speak to a paramedic who has phoned the ED for advice. He has arrived at a call where a 11 month old baby has been found dead in her cot by her parents. What is the most appropriate advice?
Answer:
All infants found collapsed or dead should be taken to the nearest emergency department with the facilities for paediatric resuscitation, including the presence of trained resident paediatricians and an anaesthetics team. As soon as possible after the arrival of the infant in the emergency department, a lead health professional should be assigned. This may be the on-call consultant paediatrician or, where suitable arrangements exist, a designated paediatrician for unexpected childhood deaths or specialist nurse. This lead health professional will take responsibility for ensuring that all health responses are implemented, and for ongoing liaison with the police and other agencies. The police should be contacted as soon as possible after the arrival of the infant in the emergency department, if this has not already been done, and arrangements made for the senior police investigator designated to lead the investigation of the death to attend. This investigator should be experienced in infant abuse/death investigation cases.Sudden Unexpected Death in Infancy and Childhood (SUDIC)
Complex Situations (SLO7) / Resuscitation
Last Updated: 8th September 2022
Definitions
Sudden Unexpected Death in Infancy (≤ 24 months) and Childhood (< 18 years): This encompasses all cases in which there is death (or collapse leading to death) of a child, which would not have been reasonably expected to occur 24 hours previously and in whom no pre-existing medical cause of death is apparent. This is a descriptive term used at the point of presentation, and will include those deaths for which a cause is ultimately found (‘explained SUDI/SUDC’) and those that remain unexplained following investigation. The majority of these guidelines focus on children aged 0–24 months.
SIDS: This refers to the sudden and unexpected death of an infant under 12 months of age, with onset of the lethal episode apparently occurring during normal sleep, which remains unexplained after a thorough investigation including performance of a complete post- mortem examination and review of the circumstances of death and the clinical history.
Background
The sudden, unexpected death of an infant or child is a tragedy for the family and all involved. Such deaths may result from previously unrecognised medical conditions or as a result of unintentional incidents. However, a significant proportion of SUDIC remain unexplained. There is evidence from national and international epidemiological studies that a significant number of sudden unexpected deaths in infants are associated with adverse environmental conditions (such as co-sleeping with carers, passive smoking, and alcohol or substance misuse by the carers). In rare cases, parental actions or actions by third parties through abuse or neglect may have caused or contributed to the death.
SUDIC guidelines provide a framework for professionals in responding to the sudden unexpected death of an infant or young child up to the age of 24 months. Many of the principles should normally be applied to unexpected deaths in older children. The aims of the response are to:
- establish, as far as is possible, the cause or causes of the infant’s death
- identify any potential contributory or modifiable factors
- provide ongoing support to the family
- ensure that all statutory obligations are met
- learn lessons in order to reduce the risks of future infant deaths
An unexpected death may be sufficiently explained – by its clinical presentation, or early laboratory or radiological findings – so that the attending doctor is able to issue a medical certificate of the cause of death (MCCD). In those situations, it may not be necessary or appropriate to institute the SUDIC guidelines. In all unexpected deaths where a medical practitioner is unable to issue a MCCD, it is the responsibility of the coroner to determine the cause of death and to ensure all statutory requirements around registration are met. However, to do this, the coroner is dependent on the information provided by the professionals involved in caring for the infant and responding to the death. All professionals involved in this joint agency response have a responsibility to work with the coroner in achieving these aims.
The joint agency response consists of the following essential components. While the manner in which these are implemented may vary in accordance with local priorities, needs and resources, no response should be considered complete without these core components:
- careful multi-agency planning of the response
- ongoing consideration of the psychological and emotional needs of the family, including referral for bereavement support
- initial assessment and management, including a detailed and careful history, examination of the infant, preliminary medical and forensic investigations, and immediate care of the family, including siblings
- an assessment of the environment and circumstances of the death
Multi-agency planning
Agencies involved:
- Health professionals
- All infants found collapsed or dead should be taken to the nearest emergency department with the facilities for paediatric resuscitation, including the presence of trained resident paediatricians and an anaesthetics team. As soon as possible after the arrival of the infant in the emergency department, a lead health professional should be assigned. This may be the on-call consultant paediatrician or, where suitable arrangements exist, a designated paediatrician for unexpected childhood deaths or specialist nurse. This lead health professional will take responsibility for ensuring that all health responses are implemented, and for ongoing liaison with the police and other agencies.
- The lead health professional should make contact with the family’s GP and health visitor or midwife as soon as possible to ensure they are fully informed, and to obtain any additional relevant medical, social or family information. In all initial and subsequent meetings with the family, consideration should be given to including a member of the primary care team where possible, in order to provide ongoing care and support to the family.
- Police
- The police should be contacted as soon as possible after the arrival of the infant in the emergency department, if this has not already been done, and arrangements made for the senior police investigator designated to lead the investigation of the death to attend. This investigator should be experienced in infant abuse/death investigation cases.
- On some occasions, particularly if concerns have been raised about neglect, non-accidental harm or unusual circumstances of the death, the police may appoint a family liaison officer to maintain close and continued contact with the family over the few days after the death. If a family liaison officer is appointed, the family must be given clear and accurate information on his/her role.
- Social services
- Local children’s social care services should also be contacted and asked to check immediately their records relating to the infant, the immediate family members, other members of the household and others with whom the infant has lived. Any relevant information identified by children’s social care should be promptly shared with the police and the paediatrician.
Key events:
- Initial information and planning meeting
- An initial information-sharing and planning discussion should take place before the family leave the emergency department. This should, as a minimum, include the lead health professional and police investigator, and should desirably include (or if not, take account of information shared from) children’s social care and the ambulance crew. The initial discussion should review the history and circumstances of the death, any immediate background information from health, police or social services, and any concerns arising from these. In particular, consideration should be given to the safety and wellbeing of any other children in the household.
- Home visit
- As soon as possible after the infant’s death, the lead health professional and police investigator, accompanied by the family’s GP or health visitor if possible, should visit the family at home or at the site of the infant’s collapse or death. The purpose of this visit is to obtain further, more detailed information about the circumstances and environment in which the infant died, and to provide the family with information and support.
- Initial case discussion
- Following the home visit, the lead health professional and police investigator should review all information gathered to date. This may be done through an initial case discussion within a multi-agency meeting, particularly where there are complex circumstances surrounding the infant’s death. Following this review, the lead health professional should prepare a report of the initial findings, to include details of the history, initial examination of the infant and findings from the home visit, as well as an account of any medical investigations
and procedures carried out. This report should be made available to the pathologist, the coroner and the police investigator as soon as possible, and preferably prior to the post-mortem examination.
- Following the home visit, the lead health professional and police investigator should review all information gathered to date. This may be done through an initial case discussion within a multi-agency meeting, particularly where there are complex circumstances surrounding the infant’s death. Following this review, the lead health professional should prepare a report of the initial findings, to include details of the history, initial examination of the infant and findings from the home visit, as well as an account of any medical investigations
- Post-mortem examination
- The aim of the investigation is to establish, as far as is possible, the cause of death. The post mortem examination will be ordered by the coroner, and should be carried out by a pathologist with up-to-date expertise in paediatric pathology. If significant concerns have been raised about the possibility of neglect or abuse having contributed to the infant’s death, a forensic pathologist should accompany the paediatric pathologist and a joint post-mortem examination protocol should be followed.
- Final case discussion
- As soon as possible, once the results of all relevant investigations have been obtained, a multi-disciplinary local case discussion meeting should be held. The local case discussion meeting should ideally take place before the coroner’s inquest and before the CDOP reviews the death. A report from the meeting should go to the coroner to assist in his or her investigation. A report should also go to the CDOP to assist in their review of the case and in identifying learning arising from the case. The purposes of this meeting are to:
- review all information pertaining to the circumstances of the death, the background history and findings of investigations in order to determine, as far as is possible, the likely cause of death and any contributory factors
- identify any lessons arising from the case that may help prevent future deaths
- consider any ongoing support needs of the family, including any information needs and care requirements of current and subsequent children
- offer a supportive environment for the professionals involved to reflect on the case and their involvement
- As soon as possible, once the results of all relevant investigations have been obtained, a multi-disciplinary local case discussion meeting should be held. The local case discussion meeting should ideally take place before the coroner’s inquest and before the CDOP reviews the death. A report from the meeting should go to the coroner to assist in his or her investigation. A report should also go to the CDOP to assist in their review of the case and in identifying learning arising from the case. The purposes of this meeting are to:
- Coroner's inquest
- The coroner has a duty under the law to make a finding as to the medical cause of death. The inquest is an investigative court hearing to determine who was the person that died and how, when and where they came by their death, the medical cause of death, and certain personal particulars that are required for registering the death. If the medical cause of death is known following the inquest, it is recorded on the Record of Inquest and the Rev 99 form, and passed to the registrar. If the medical cause of death cannot be ascertained, it should be recorded on the Record of Inquest and Rev 99 as ‘Unascertained’.
- Child Death Overview Panel (CDOP)
- The Child Death Overview Panel (CDOP) is a multi-agency panel set up to systematically gather comprehensive data on children’s deaths, to identify notable and potentially remediable factors, and to learn lessons and make recommendations to reduce the risk of future child deaths. The CDOP manager should be notified according to local protocol whenever an infant dies. For sudden unexpected deaths, this should be done following presentation by the lead health professional. At the conclusion of the joint agency response, a copy of the report of the final case discussion should be sent to the CDOP manager for inclusion in the documentation compiled for the CDOP meeting.
Family support
- Immediately upon their arrival at the hospital, the family should be allocated a member of staff to care for them, explain what is happening and provide them with facilities to contact friends, other family members and cultural or religious support.
- Where attempts are made at resuscitation, the member of staff allocated to the family should ensure that the family is kept fully informed during the course of the resuscitation and, subject to the approval of the medical staff involved, the family should be given the option to be present during the resuscitation. The allocated member of staff should stay with the family throughout this period to explain what is going on.
- It will normally be appropriate for the family to hold and spend time with their infant once death has been confirmed. This may happen in appropriate circumstances after discussion with the lead investigator, even if there are suspicions of possible abuse or neglect contributing to the infant’s death, but there must be a discreet professional presence.
- Consideration should be given to the capacity of the family to engage in the processes unfolding around them. Particular consideration should be given to issues of language, health or mental capacity. Further considerations must also be given to the faith and culture of the infant and their family.
- The family should be told at an early stage that, because their infant’s death was unexpected, the coroner will need to be informed and there will need to be a police investigation. This must be explained to the family in a sensitive way, emphasising that these are routine procedures that are followed in any unexpected infant death. The purpose and process of the joint agency response should be explained to the family, emphasising that all professionals are working together to try and help them understand why their infant has died and to support them.
- Unless the cause of death is immediately apparent, the family should be informed that the coroner is likely to order a post-mortem examination. The family should be informed about the post-mortem examination, including the likely venue and timing, any arrangements for moving their infant, and the likelihood that tissues will be retained during the post-mortem examination (following the coroner’s investigation, the family can then determine the fate of the tissue according to the Human Tissue Act 2004). The family should be made aware that it may take several weeks to secure the results of the post-mortem examination and for the coroner to come to a conclusion.
- Written information is important and valuable to the family, because much of the detail of what is discussed can be forgotten or lost in the immediate stress of their infant’s death. It is important that the family are provided with relevant and up-to-date information, but are not overwhelmed by this. The Lullaby Trust produces a comprehensive leaflet, When a Baby Dies Suddenly and Unexpectedly which can be shared with families at the earliest opportunity.
- Under the Police and Criminal Evidence Act 1984,29 if the police investigator has suspicions that the death may be a crime, the law demands that the suspect’s rights are protected and certain legal restrictions apply in terms of how they can be spoken to, and by whom. This is particularly relevant where the possible suspect is a family member. It should be noted that Section 66 of the Serious Crime Act 201530 amends Section 1(2)(b) of the 1933 Children & Young Persons Act,31 such that it is now an offence when a child dies through suffocation while sleeping with an adult, where the adult is under the influence of alcohol or ‘prohibited drugs’.
- Since by definition the cause of death in SUDI is not known, it is important that all organs are examined carefully during the post-mortem examination. For this reason, the potential beneficial effects that organ donation may afford bereaved families are not available in the case of SUDI. If a family voluntarily raises this possibility, they should be sensitively informed that it is not an option in their infant’s case. In situations where an infant has an unexpected cardiac arrest, is resuscitated and stabilised on an intensive care unit, but a decision is made subsequently to withdraw care, there may be opportunities for organ donation if the cause of death is known.
Initial assessment and management
- Prehospital
- On receipt of a 999 call indicating that an infant has been found unexpectedly collapsed or dead, the call centre should immediately notify ambulance control to dispatch an ambulance crew and, where appropriate, a first responder. The police should also be notified and an officer dispatched to the scene. On arrival at the scene, the first responder or ambulance crew should carry out an immediate appraisal of the circumstances. Unless there are clear indications that the infant has been dead for some time, appropriate resuscitation should be started and continued until the infant is brought to hospital.
- The paramedic/ambulance crew should inform the emergency department of the hospital that an infant has been found unexpectedly collapsed or dead and to have the resuscitation team on stand by and anticipating the arrival of the infant/child. The first responder/ambulance crew should elicit a very brief initial account of the circumstances and whether there are any infant medical issues, such as any relevant past medical history or current medication for the child. They should note their impressions of the environment in which the infant was found, and any concerns about care. A copy of the ambulance crew’s record should be provided to the lead health professional and police investigator.
- Unless there are exceptional reasons not to, the infant should be brought immediately to an emergency department with paediatric care. Resuscitation should be continued en route to the hospital. Arrangements should be made for the family to attend the emergency department, either accompanying the infant in the ambulance or separately. Consideration should be given to the care and welfare of any other children in the home. The attending police could assist with these arrangements.
- If there are signs that the infant is clearly dead and has been for some time, for example, the development of rigor mortis or dependent livido, resuscitation would not be appropriate. This should be discussed with the family. In most circumstances, it will still be appropriate to transfer the infant and family to an emergency department with paediatric facilities where the joint agency response may be initiated, the infant can be examined and appropriate immediate medical investigations carried out. If there are immediate indications of abuse, neglect or an assault contributing to the death, the police should take the lead in the management, under the direction of an investigating officer. In such circumstances, and if the infant is clearly dead, it may not be appropriate to move the infant and the scene should be secured as for any potential crime scene.
- Immediate management in ED
- In the emergency department, the care of the family and the investigation of the cause of the death should follow a similar course, whether or not resuscitation has been attempted. The decision to stop resuscitation should be made by a senior medical practitioner (usually the consultant paediatrician or consultant in emergency medicine) after discussion with the resuscitation team and the family. Once a decision has been made to stop resuscitation, an appropriately qualified medical practitioner should confirm that the infant is dead, in accordance with established guidelines. Confirmation of the fact of death and the time should be recorded in the infant’s notes.
- Once death has been confirmed, the consultant paediatrician on call or the designated SUDI paediatrician should carefully and thoroughly examine the infant. The police investigator should be present while this happens. A particular note should be made of any marks, abrasions, rashes, evidence of dehydration or identifiable injuries at this time, in addition to a detailed general examination. The presence of any discolouration of the skin, particularly dependent livido, should be carefully and accurately documented, along with other post-mortem changes such as frothy blood-stained fluid from the airways and rigor mortis. Where possible, the eyes should be examined by direct fundoscopy for the presence of retinal haemorrhages. All findings should be carefully documented in the notes and on a body chart. The infant should be weighed and measured (length and head circumference), and the measurements plotted on a centile chart.
- Once the infant has been examined and all findings recorded, along with medical or police photographs where indicated, and sampling taken, the infant can be cleaned and dressed and given to the family to hold if they wish, unless there are suspicious findings that preclude such actions. If they wish, the family should be offered the option of cleaning and dressing their infant in an appropriate setting. Health staff in the emergency department should offer the family the option of mementos being taken such as handprints, footprints, a lock of hair and photographs. If there are suspicious circumstances surrounding the death, the taking of mementos should be discussed with the investigating officer to ensure this does not interfere with any investigation; in such circumstances it may be appropriate to delay this until after the post-mortem examination.
- Subsequent management in ED
- The lead health professional (consultant paediatrician on call, designated paediatrician or specialist nurse) should take a detailed and careful history from the family. Where possible, this should be carried out with the police investigator to avoid the need for repeated questioning. The history should include a careful review of the past medical history, including pregnancy and birth, the infant’s growth and development, any relevant social and family history, and the events leading up to and following the discovery of the infant’s collapse. The Personal Child Health Record (‘Red Book’) may also be an important source of information. Relevant family history, birth details, immunisation status, growth trajectory, outcome from routine reviews and other information about the infant may be found in it. The information obtained from these sources, including the ambulance record should be recorded on a standard SUDI proforma, commenced in hospital and taken to the home visit.
- During the process of resuscitation, various medical investigations may be initiated, including blood samples for electrolytes and blood cultures. If these have not been obtained during resuscitation, they should be obtained via a post-mortem sample, along with blood for metabolic investigations. Any samples collected post-mortem must be removed from the body on HTA-licensed premises. The police investigator should arrange for appropriate documentation and transportation. Any samples collected post-mortem are the property of the coroner. A single attempt at a femoral or cardiac aspiration should be made by a competent practitioner. A single attempt at urethral catheterisation or supra-pubic aspiration should be made and, if urine is obtained, it should be sent for microscopy and culture, metabolic investigations and toxicology. A single attempt at a lumbar puncture should be made and, if obtained, a sample of cerebrospinal fluid sent for microscopy and culture. Any stool or urine passed by the infant, together with any gastric or nasopharyngeal aspirate obtained, should be carefully labelled and frozen after samples have been sent for bacterial culture and for virology. If the nappy is wet or soiled, it should be removed, labelled and frozen. The lead health professional should arrange for a full radiological skeletal survey or other appropriate imaging to be undertaken. Imaging investigations should be reported on as soon as possible in order to identify or rule out bony injuries, as this may change the focus of the investigation.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
