Toward a standardized investigation protocol in sudden unexpected deaths in infancy in South Africa: a multicenter study of medico-legal investigation procedures and outcomes.

INTRODUCTION: South Africa manifests a socio-economic dichotomy that shows features of both a developed and developing country. As a result of this, areas exist where a lack of resources and expertise prevents the implementation of a highly standardized protocol for the investigation of sudden and unexpected deaths in infants (SUDI). Although the medico-legal mortuaries attached to academic centers have the capacity to implement standardized protocols, a previous study conducted at two large medico-legal mortuaries indicated otherwise. This study also revealed that the exact number and incidence of sudden infant death syndrome (SIDS) cases was unknown. These findings prompted a multicenter study of the medico-legal investigation procedures and outcomes in five academic centers in South Africa.
METHODS: A retrospective case audit was conducted for a 5-year period (2005-2009) at medico-legal laboratories attached to universities in Bloemfontein, Cape Town-Tygerberg, Durban, Johannesburg, and Pretoria. The total case load as well as the total number of infants younger than 1 year of age admitted to these mortuaries was documented. The case files on all infants younger than 1 year of age who were admitted as sudden and unexpected or unexplained deaths were included in the study population. Data collected on the target population included demographic details, the nature and scope of the post-mortem examinations, as well as the final outcome (cause of death).
RESULTS: A total case load of 80,399 cases were admitted to the mortuaries over the 5 year period with a total of 3,295 (6.5 %) infants. In the infant group, 591 (0.7 %) died from non-natural causes and 2,704 (3.3 %) cases of sudden, unexpected and/or unexplained deaths in infants were admitted and included in the detailed case analysis study. One hundred and ninety-nine babies were between 0 and 7 days of age and 210 babies between 8 and 30 days. The remaining 2,295 infants were between 1 month and 12 months of age. Death scene investigation was done in a total of 14 (0.5 %) cases. Discrepancies were present in the extent of the macroscopic post-mortem examinations, as well as the type and extent of the ancillary investigations performed. The investigations were completed in 2,583 of the cases. The majority of these infants died from natural disease processes [1,976 infants (76.5 %)]. Bronchopneumonia was the leading cause of natural deaths at all the mortuaries [674 cases (26.1 %)]. SIDS was diagnosed in only 224 cases (8.7 %) and in 383 (14.8 %) cases, where a full post-mortem examination with ancillary investigations was conducted; the cause of death was recorded as "unascertained."
CONCLUSIONS: This study indicated that the admission criteria (to medico-legal mortuaries) and the investigative process/protocols in cases of SUDI differ greatly among 5 of the largest academic medical institutions in South Africa. Establishing and implementing standardized admission criteria (to medico-legal mortuaries) and implementing uniform investigative and autopsy protocols would appear to be an essential prerequisite to gain better understanding of the mystery of SIDS in South Africa.