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You work in a general practice. You are counselling the family of a four-month-old male infant who was rushed to the Emergency Department of the local hospital the day before but was dead on arrival. The provisional diagnosis is sudden infant death syndrome (SIDS) and the baby (Andrew) is to have a Coronial autopsy. You had seen him for the first time two months previously, with his single mother, when he was thriving and developing normally and had commenced immunisations. Two days before his death you saw him again, this time with mild upper respiratory snuffles which were causing minor difficulties with breastfeeding. However, over the next two days he apparently improved, and his mother had advised you that he appeared normal and fed well from the breast just prior to his death. You are unaware of any suspicious circumstances surrounding the death. The family members have attended to seek details of why the baby died and why an autopsy is necessary. The spokesperson for the group is the mother's sister, the aunt of the infant. The mother is also present, but is too distressed to ask any questions herself.

The examiner will have instructed the relative as follows: You are the aunt of an infant who died, apparently of SIDS, the day before. The family members including the young single mother have attended to ask questions about the baby's death but the mother is still too distressed to ask them herself. You are the spokesperson of the family.

Opening statement :

 ‘We can't understand why Andrew has died!'

Questions to ask unless already covered: 

• ‘Why do the police have to be involved? Do they think my sister killed her baby?'
• ‘Why does he have to have an autopsy?' 
• ‘When will we get further information and results of this?'
• ‘When can we arrange his funeral?'
• ‘We feel so alone. Is there anyone we can talk to about this?'
• 'Should the snuffles have been treated?'

Additional history

Systems review

These clinical findings are available on a separate sheet that is to be handed to candidates when they ask for any physical examination findings.

Surgery test results

Random blood glucose:                 5.5 mmol/L

ECG:                                                      Normal sinus rhythm

Urine dipstick:                                   Leukocytes+

                                                                Nitrite- negative

                                                                Blood- negative

                                                                Glucose- negative

                                                                Ketones- negative

Urine for pregnancy                                        Negative

Spirometry                                         Normal

Candidates are to ask for specific investigations.

Accordion Sample Description

Explanation of diagnosis

The most likely cause of the child's death is SIDS. Candidates should explain what is known about SIDS along the following lines: 

• The frequency of SIDS has fallen from 1 in 500 live births to now approximately 1 in 1000;
• The peak incidence occurs at about four months of age; and
• There are no certain causes known. Many theories exist, but none is proven.

 Explain that there can be other causes of sudden infant death (for example, overwhelming infection), but the child's history does not suggest this cause. Andrew's snuffles were not a warning sign and there is no suggestion that any medical treatment would have influenced the outcome.

Immediate management following a death due to apparent SIDS — should be advised empathically as follows: 

• Explain that the police and the Coroner must be notified by law because Andrew's death was sudden and unexplained.
• Explain that the role of the Police Officer is to assist the Coroner — police are required to interview all people concerned including the baby's general practitioner.
• Explain the need for the autopsy in all cases, and that autopsies are done by very experienced pathologists in an attempt to find out what causes SIDS, and to exclude other possible causes of death.
• Explain that tissues will be removed for further examination under the microscope.
• Offer to contact the Coroner later to obtain information on the initial findings after the autopsy has been performed or advise that the Coroner's office will contact the mother at a later date to giver further information. 
• Offer to contact other family members for support for the mother.
• The Coroner will decide if an inquest needs to be held, but with SIDS this is generally not necessary.
• Offer to contact the local SIDS Support Group, if one is available.
•  

Future management Followup contact with family and with the Coroner/pathologist to confirm diagnosis. Liaise with support group in counselling the mother when results are available.

• Appropriate empathic explanation.
• Ability to explain the involvement of appropriate authorities and support groups.
• Offering to arrange for continuing followup, contact and support with the family.

• Failure to display empathy in counselling. 
• Failure to recognise and explain need for coronial notification and autopsy.

Empathy in communication is essential in these tragic circumstances, together with accurate knowledge of legislative requirements. All deaths under these circumstances must be reported to the Coroner and the police must take statements. This is often the most distressing part of the process for young parents and should be explained carefully to the family why this process needs to happen by law. The caring practitioner will also offer to liaise with the Coroner on behalf of the parents, and in this way is often able to receive preliminary reports if the Coroner is agreeable to them being released, which many Coroners are. Several pathologists who perform these autopsies actually interview the parents themselves when the autopsy is completed. The caring practitioner will offer to keep contact with the grieving couple or parent until confident that this tragic event has been accepted.