Colleagues must ensure they are familiar with national SUDIC protocol and their role within it.

The Sudden Unexpected Death in Infancy and Childhood (SUDIC) protocol is a national, multi-agency process used whenever a baby, child or young person dies unexpectedly. This includes sudden and unexpected deaths within neonatal units and other healthcare settings. Its purpose is to ensure that every unexpected death is investigated thoroughly, sensitively and consistently, while providing support to bereaved families throughout the process. 

The protocol brings together healthcare professionals, police, coronial services, social care and other agencies to:

  • Establish, wherever possible, the cause of death.
  • Identify any factors that may have contributed to the death and opportunities for learning.
  • Ensure families receive compassionate, clear and ongoing communication and support.
  • Meet safeguarding and statutory and professional responsibilities.
  • Support organisational learning and help prevent future deaths
  • Identify any factors that may have contributed to the death.
  • Support and communicate with the family compassionately.
  • Meet safeguarding and statutory responsibilities.
  • Learn lessons that could help prevent future child deaths. 

Key elements of the protocol include:

  • An immediate multi-agency response following the death.
  • Early notification and involvement of the Coroner where required
  • A detailed review of the circumstances and environment in which the child died.
  • Timely information sharing between professionals and agencies involved with the child’s care.
  • A specialist post-mortem examination and further investigations where necessary.
  • Multi-agency case discussions to review findings, identify learning and contribute to determining the cause of death where possible.
  • Ongoing support and communication with families throughout the investigation process.

What this means for colleagues

All colleagues should:

  • Recognise and promptly escalate concerns relating to unexpected deterioration or death in infants, children and young people.
  • Ensure accurate, contemporaneous clinical documentation is completed.
  • Participate openly and constructively in review and investigation processes.
  • Share information appropriately and work collaboratively with partner agencies.
  • Support a culture of speaking up, professional curiosity, candour and continuous learning.
  • Ensure families are treated with compassion, dignity and respect at all times.

The SUDIC protocol ensures a coordinated, compassionate and evidence-based approach to investigating unexpected child deaths, supporting families and helping organisations learn from every case.

For further information about SUDIC, please contact:

Read the full protocol on The Royal College of Pathologists website.