Joint statement on eye examination in Sudden Unexpected Death in Children

This statement from Royal College of Paediatrics and Child Health, Royal College of Pathologists and Royal College of Ophthalmologists sets out clarity on the examination of the eyes in a sudden unexpected death of a child (SUDIC).

We are recommending that this statement is an addendum to the 2016 Kennedy report until the next official review takes place.

The report, ‘Sudden unexpected death in infancy and childhood: Multi-agency guidelines for care and investigation’ (known as the Kennedy Report) in 2016 was developed by a working group convened by the Royal College of Pathologists and endorsed by the Royal College of Paediatrics and Child Health.

The report provides guidelines for all professions involved in the examination of sudden unexpected death of a child and outlines best practice for each part of the investigation process. The original guidelines published in 2004 followed high profile cases of miscarriages of justice involving the prosecution of mothers for causing the deaths of their babies. These events raised serious concerns about the role of the expert witness in court, issues about standards of proof, the quality of evidence and about the procedures adopted for the investigation of sudden unexpected deaths of infants.

We believe it is of extreme importance that the child’s eyes are examined as soon as possible after any unexplained death and therefore can be carried out by any senior clinician, which would most likely be a paediatrician.

When practicable and where swift examination can occur, the senior clinician can contact an ophthalmologist, following locally agreed protocols. 

The expectation is that the clinician records what it is possible to see, including the presence or absence of retinal haemorrhages in each eye, with an accompanying proviso about their degree of expertise and that they are unable to make any comment on the interpretation of significance. Other professionals will use this information to help inform the most appropriate next steps in the investigation process of the child’s death.

Retinal haemorrhages in living infants are generally accepted to be a possible indicator of abusive head trauma. Although there are a number of alternative aetiologies, retinal haemorrhages are such an important feature of child abuse, they require evaluation within the context of a thorough clinical assessment. In many cases, a clear view of the retina may not be possible due to corneal clouding following death. 

Little has been published on ophthalmological examination in the early post mortem period. However, the presence of multiple retinal haemorrhages could imply that the infant has died of unnatural causes. The detection of retinal haemorrhages immediately post mortem, particularly where there are no other immediately obvious concerning features of unnatural death, may lead to a formal forensic post mortem process. Importantly, this will include the engagement of a forensic pathologist to perform the autopsy and the initiation of the process that adequately protects any living siblings.