First ever study of serious case reviews of sudden unexpected infant deaths

For the first time in England a study has been conducted of official investigations of unexpected infant deaths.

  • Domestic violence, mental health problems and substance misuse highlighted as factors
  • Most cases occurred when intoxicated parents shared sleeping surfaces with child
  • Many happen following a sudden change in family circumstances

The research was conducted by academics at the University of Warwick who aimed to develop a detailed understanding of the circumstances of sudden unexpected death in infancy (SUDI) cases subject to serious case review.

The team led by Dr Joanna Garstang from the Division of Mental Health and Wellbeing, Warwick Medical School found that most SUDI cases occurred in hazardous sleep environments and are potentially preventable. They also found that they occurred in families well known to services with concerns about neglect, substance misuse and poor engagement.

Sudden unexpected death in infancy (SUDI) remains a significant problem with around 300–400 SUDI cases annually in England and Wales. SUDI is defined as the sudden and unexplained death of an infant that had not been considered as a reasonable possibility in the previous 48 hours.

The paper, Qualitative analysis of serious case reviews into unexpected infant deaths examined serious case reviews in England from April 2011 to March 2014. These were cases of infants aged 0-2 for whom no clear medical or forensic cause of death was found. The researchers gained access to 27 out of the 30 reviews that were held during the time period. They found in 18 cases parents did not engage with professionals, 18 families suffered alcohol or drug dependency, there were 14 cases of parental mental health problems, in 13 cases parents had criminal records and there were nine cases of domestic abuse. The analysis of the 27 reviews also highlighted that 18 deaths occurred in highly hazardous sleep environments; 16 of those involved cosleeping and 13 of those occurred with parents who were drunk or had taken drugs.

The paper which is published in the Archives of Disease in Childhood concluded that more consideration is needed on how best to support such vulnerable families.

“Despite 25 years of safe sleep campaigns, some parents are still not receiving, not hearing, not understanding, or choosing not to follow this advice, resulting in many infants being exposed to hazardous sleep situations. Future research needs to focus on how best to support and engage with these vulnerable families.”

Leave a comment

This site uses Akismet to reduce spam. Learn how your comment data is processed.