Review of the Sussex multi-agency protocol for when a baby dies 

28 January 2005

The Sussex multi-agency protocol was introduced in 1999 to improve the way unexpected child deaths are investigated, aiming to guide professionals so that investigations are thorough and accurate but sensitive and helpful to the family.

Dr Anne Livesey, Consultant Community Paediatrician in Brighton, looked back over the protocol's first three years.  Her review was supported by FSID, Sussex coroners, police and health professionals.

Parents and professionals were invited to give anonymised feedback by questionnaire or interview with Dr Livesey or Eleanor Ennis, FSID's Regional Coordinator.

Thirty babies died unexpectedly during this time. Most deaths were reported as SIDS or unascertained but another cause was found for one in three. Nearly all post mortems were done by paediatric pathologists but there were some inconsistencies in terms of which additional tests were done. There were also gaps in the implementation of the protocol which could have been avoided with better communication.

Although half of parents contacted gave feedback, over one third could not be invited to respond because they had moved or because their GP did not think it was appropriate. 

Parents'  experiences varied and included positive feedback and appreciation of particular professionals. There were also criticisms, particularly of the lack of bereavement support for some families and the inevitable involvement of the police. One family felt that advice for brothers and sisters was lacking.

One of the main achievements of the protocol has been getting agreement among professionals about their roles and responsibilities following the death of a child. Protocols are not always followed for a number of reasons; there is a continuing need to keep professionals aware of guidelines and receive feedback. In Sussex it is hoped that parents will routinely be offered an opportunity to do this.


This research is published in: Dr Anne Livesey, A multi-agency protocol for responding to sudden unexpected death in infancy: descriptive study. BMJ, 28 January 2005.