Factores claves del éxito en el sector del Comercio Minorista de Bienes

The vast majority of SUDI cases in the study area have post-mortem examinations at the Department of Perinatal Pathology at Birmingham Womens’ Hospital; two or three SUDI cases a year have post-mortem examinations at Birmingham Children’s Hospital. Both these pathology departments were telephoned for details of SUDI cases on a bi-monthly basis. To preserve confidentiality the pathology department only disclosed for each case the dates of birth and death, the referring hospital and the name of the local SUDI paediatrician.

SUDI paediatricians were emailed or telephoned about the relevant cases from their area; although cases were only identified by dates of birth and death as these were rare events the paediatricians were easily able to recall the names of the infants so access the families’ contact details. The SUDI paediatricians were asked to outline the study to the parents at a follow-up meeting after the final case discussion; this is typically 4 to 6 months following the death but for some cases was over a year after the death. The SUDI paediatrician gave the parents an introductory study letter and pre-paid reply form to be completed if parents wanted to participate. Parents were also given another pre- paid reply form to return if they subsequently wanted to withdraw from the study; there was also a 24 hour answer phone number for this purpose. A set of study paperwork for each case was sent to the SUDI paediatrician to be kept in the clinical notes as a reminder; paediatricians were also reminded about recruitment by child death administrative staff. In some areas the role of the SUDI paediatrician is carried out

141 by a specialist nurse. In these cases the specialist nurse was asked to approach the family in the same way as the SUDI paediatrician.

I telephoned parents approximately 2 weeks after the reply form was received; this allowed them time to change their minds prior to the telephone call. During the call, I outlined the 3 options for the study : a home visit with an in-depth interview with case note analysis, a self-completion questionnaire to be returned by post with case note analysis, or case note analysis alone. Telephone contact was chosen as bereaved families have valued this approach previously and if telephone contact is not made parents of lower literacy levels may not respond (Meert et al., 2008a, Hynson et al., 2006)

For parents who opted for an interview, an appointment was to be made to visit them, usually at their home. At the visit the study was explained fully and informed consent to participate obtained. For parents who chose to complete a questionnaire or partake in the case note analysis alone consent forms and questionnaires were sent by post with a prepaid reply envelope included.

A website was set up to try and increase recruitment knowing that significant numbers of parents were not being told about the study by their local paediatricians. This website was advertised by The Lullaby Trust, the national charity for SUDI research and parent support, using their website, Facebook page and Twitter feeds. There were no enquiries received from parents via the website.

This was a complex way of contacting parents but it was an ethical requirement. Clinical researchers are not able to access identifiable patient details for research projects unless they are part of the patient’s clinical team; which I was not. I therefore had to rely on SUDI paediatricians to help in recruitment although I was well aware that in

142 previous similar studies local clinicians have limited researcher’s access to bereaved families (Dent et al., 1996).

In-depth interviews and questionnaires

The original plan had been for all parents to complete an initial structured interview at around six months after the death; the structured interview would then guide the purposive sampling for in-depth interviews at approximately one year after the death. This method was revised to offer parents a choice of in-depth interview with case note analysis, self-completion questionnaire with case note analysis, or case note analysis alone. Recruitment had been very slow with many parents not recruited until at least a year after the death; after the first few structured interviews it became clear that most parents wanted to tell their stories in some detail and not be constrained by the questionnaire used in the structured interview. In addition, some parents had declined the study but fed back to their SUDI paediatrician that had they had the option of completing a questionnaire without having to talk to a stranger about events they would have felt able to participate. The structured interview questions were identical in content to the self-completion questionnaire.

When planning the project bereaved parents advised that at least four years were needed after the death before parents could make sense of the events due to their grief. With this in mind follow-up in-depth interviews were planned for parents

recruited in the first two years of the study, these interviews took place between 22 and 28 months after the death. These were only possible for cases where infants had died between 1 September 2010 and 31 August 2012 in order to be able to complete the whole project on time.

143 The original investigation, whether there was a home visit and by whom?

How did the parents feel about the investigation?

What support they received following the death and from whom? Parental knowledge of the cause of death of their baby.

Parental physical and mental health since the death Parental employment and time off work after the death. Parental smoking, alcohol and drug use.

The parental in-depth interview schedules are shown in appendix 4 and structured interview or self-completion questionnaires in appendix 6. Bereaved parents gave advice on the development of the interview schedule and questionnaire.

Prior to the interview I had received no information about the case; the first account of events and cause for death that I heard was from the parents. During my visit, but after the interview, parents were asked to complete the questionniare.

In-depth interviews were audio recorded and field notes written. In depth interviews lasted between one and five hours; the median time was 2.5 hours. All interviews were conducted in English as this was preferred language of all participating parents. A professional transcriber did the in-depth interview transcription.

The Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983) was completed by all parents having interviews or completing questionnaires and repeated for those who had follow-up interviews. The Hospital Anxiety and Depression Scale is shown at appendix 5.

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Case note analysis

The rationale for collecting the case note data was to allow an assessment of the process and outcomes of the JAA, to help further understand parental experiences and allow triangulation of data. The outcomes of the JAA relate to its aims: establishing the cause and risk factors for death and addressing the needs of the family. The process was assessed using details of JAA events recorded in police and health records to ascertain exactly what happened and these were compared with the JAA as described in the West Midlands protocol (West Midlands Police, 2009). This could then be triangulated with the parents’ and professionals’ views on JAA events. The outcomes were assessed from information on cause of death and risk factors from health and coroners’ records as well as details of any social care involvement with the family after the death. Data on causes and risk factors for death were also triangulated with parental understanding of the cause of death; I could not assess their understanding without being able to compare with the documented cause. I used background information on families from police and social care records to help understand parental experiences.

The case notes from health, police, and social care were studied for all cases. I attended a meeting of the senior police officers for Child Protection for each force in the study area (West Midlands, West Mercia, Staffordshire and Warwickshire); following this I was allowed unrestricted access to police case records for all cases. In contrast, access to social care records was often extremely difficult, this was compounded by the fact that each local authority (cases came from ten different local authorities) had different research access procedures. Frequently, I contacted the Child Death Overview Panel administrator prior to contacting social care as they routinely obtain social care

information about every child who dies. If the family had not been known to social care I did not contact social care to seek further access to their records. Health records were

145 accessed without issue as research and ethical approval had been granted by every relevant NHS trust in the region. The ethical approvals are shown at appendix 9.

The case notes from health included infant hospital records, SUDI case records from the SUDI paediatrician, minutes from initial and final case reviews and post-mortem

examination reports. I developed a standard proforma for data extraction based on my clinical practice in managing SUDI cases; this was trialled on the first two cases then revised. The health records proforma is shown at appendix 7.

I studied health records for events of the JAA; hospital records for details of events in the Emergency Department, SUDI case records for joint home visits, follow-up appointments and other contacts with parents and case review minutes for details of who attended and when meetings were held. Outcomes from health records included the final cause of death and risk factors identified according to case review minutes and post-mortem examination reports.

I extracted data from police records using a standard proforma; this was developed with a police officer experienced in managing SUDI cases. I studied records for background information on families such as prior parental convictions or domestic violence and events of the JAA such as police actions at the time of the death, forensic investigations at the scene and property taken (for example baby clothes and feeding bottles). The police records proforma is shown at appendix 7.

I requested a copy of the coroner’s inquisition (inquest verdict) for each case directly from the coroner’s office.

I extracted data from social care records using a standard proforma; this was developed with a social work manager who was experienced in working in child protection. I studied records for background information on involvement with the family prior to

146 death and outcomes such as details of any investigations after the death or child

protection involvement subsequent to death for surviving siblings. The social care records proforma is shown at appendix 7.

In most cases I saw the whole case file and extracted the data myself, in a few cases photocopies of case files were sent by post. In two social care cases social workers completed the proforma themselves and I did not see the case files. I entered data from the completed proforma into an excel workbook.

General Practice Records

The GP records were relevant as they contained information about parental wellbeing; bereaved families are likely to seek information about the death or emotional support from GPs after sudden deaths (Merlevede et al., 2004).

I requested a computer summary printout for all parents for all consultations in the year following the death. This was readily available for most cases although some families were not registered with GPs resulting in no records being available. I recorded the number of consultations during the year, excluding any for maternity services. I coded consultations as to whether they were for bereavement support, acute illness or chronic (pre-SUDI) illness.

Interviews with Professionals

Interviews with professionals took place for the cases where parents had opted to have in-depth interviews. The professionals were SUDI paediatricians, SUDI specialist nurses, police officers and social workers; I attempted to interview all of these professionals for each case although only a minority of families had social workers. The paediatricians and nurses were identified as part of the process of recruiting the families; they usually had contact details for the police officers if not I was able to obtain these via other

147 police contacts. Social workers’ contact details were obtained from the social care case records. In a few cases, professionals could not be identified or had moved posts so could not be contacted.

Professionals were either interviewed in person, after I had viewed the case records or by telephone at a later date. Professionals were asked about the details of the JAA investigation, their involvement with the family, how the multi-agency working had proceeded, and their views on the JAA in general. In some cases professionals were asked to clarify events from the case records or were asked about the rationale for certain decisions such as the reasoning for using police tape to seal off houses. Interviews were audio recorded and transcribed; they lasted between 10 and 45 minutes.

Ethical Issues

All elements of the WMSUDI study were approved by the Solihull NHS Research Ethics Committee without issue.

Research with bereaved parents is a sensitive area and there were safeguards in place to protect families. The bereaved parents were contacted in the first instance by their local SUDI paediatrician about the research study; in several cases the paediatricians did not feel it was appropriate to ask the parents due to mental health concerns, fragile parental relationships or domestic violence. Once parents had agreed to be contacted about the research project there was a two week delay prior to them being telephoned about the study to allow them further time to change their minds. Similarly, interview dates were always arranged at least two weeks ahead so not rushing parents into decisions about participation. At the start of each research interview parents were told in detail about the study and reminded that they could stop the interview or withdraw

148 from the study at any point during the interview or subsequently. Often parents needed to stop the interview when upset but in all cases, having recovered their composure, parents wanted to continue. At the end of the interview, parents were given an

information sheet with details of the Lullaby Trust so they could access these services if needed. I attempted to telephone all parents a few days after the interview to check that they had recovered from the interview. No one reported any further problems but I was not able to contact some families.

In some instances, it was clear that parents had significant mental health issues either from their in-depth interview discussions or completion of the HADS questionnaire. I discussed these with the parents at the time of the interview and suggested that they contact their GP or the Lullaby Trust for further help. In some cases I offered to contact the GP on their behalf.

As part of the informed consent process, parents were told that if they disclosed information that could lead to concerns that any child (living or dead) may be at risk of abuse or may have been previously, further action would need to be taken. This would involve discussing the case with PS (who is a Designated Doctor for Child Protection) and possibly referring the matter to police and social care. I did have to make a child

protection referral for one family, where the mother had significant mental health issues that were impairing her ability to care for her remaining children.