for responding to unexpected child deaths were
introduced throughout England. There has, to date, been
no national audit of these procedures.
Study design. Families bereaved by the unexpected
death of a child under 4 years of age since 2008 were
invited to participate. Factors contributing to the death
and investigations after the death were explored.
Telephone interviews were conducted, and coroners’
documents were obtained. The nature and quality
of investigations was compared with the required
procedures; information on each case was reviewed by a
multiagency panel; and the death was categorised using
the Avon clinicopathological classification.
Results. Data were obtained from 91 bereaved families
(64 infant deaths and 27 children aged 1–3 years); 85
remained unexplained after postmortem examination.
Documentation of multiagency assessments was poorly
recorded. Most (88%) families received a home visit from
the police, but few (37%) received joint visits by police
and healthcare professionals. Postmortem examinations
closely followed national guidance; 94% involved
paediatric pathologists; 61% of families had a final
meeting with a paediatrician to explain the investigation
outcome. There was no improvement in frequency of
home visits by health professionals or final meetings with
paediatricians between 2008–2013 and 2014–2017 and
no improvement in parental satisfaction with the process.
Conclusions. Statutory procedures need to be followed
more closely. The implementation of a national child
mortality database from 2019 will allow continuing audit
of the quality of investigations after unexpected child
deaths. An important area amenable to improvement is
increased involvement by paediatricians.