CORRESPONDENCE

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Sudden infant death and

suffocation
SIR,-We find Professor Roy Meadow's reply to
correspondence about his article on suffocation
even more surprising than the original.'
If he equates cot death with sudden infant death
syndrome-as the use of "sudden infant death
syndrome (cot death)" implies-then his statement
that "well documented cases of cot death are
subsequently found to be caused by suffocation" is
difficult to comprehend. There are no findings at
necropsy about the cause of death in sudden infant
death syndrome; in the absence of excessive
pressure on the neck or other excessive violence
there are no findings at necropsy in a death caused
by suffocation. Without objective pathological
evidence suffocation cannot be proved, so how can
it be found? Apparent confessions by mothers are
difficult to interpret and would be an insufficient
basis for successful prosecution.
If there is objective pathological evidence of
injury to the neck or airways then the death
would not be regarded as due to the sudden infant
death syndrome. If 2-10% of cot deaths are due to
suffocation then 30-150 infants die from suffocation
each year in the United Kingdom, according to
Professor Meadow. It seems strange that we, as full
time forensic pathologists, have not noticed this
huge addition to the workload of the criminal
court.
ro abolish the term sudden infant death
syndrome would require the cause of death in
these cases to be stated accurately as "unascertained." It was to prevent consequent inquests and
further distress to grieving parents (at least 90%No of
whom would be genuinely innocent if one accepted
Professor Meadow's highest estimate of suffocation) that the term was introduced. As practitioners
who actually have to make the diagnosis we find
Professor Meadow's wish to abolish the term
presumptuous and his statement "the syndrome
label is being used inappropriately as a diagnosis"
offensive. If this statement is based on semantic
misgivings it sits poorly with his penultimate
sentence: intervention is impossible after death
although the prevention of further deaths may be
possible.
Suffocation as a form of child abuse must be
viewed in the context of the criminal court:
statements and arguments regarding it should be
made in that same context, being based on the
objective evidence in the individual case. Such
evidence is lacking in both Professor NMeadow's
original article and his reply; epidemiological
inferences based on an anecdotal, circumstantial,
uncontrolled database are no substitute.
We view with trepidation the inclusion of such
unsupported statements in a series of articles
which will be read by trainee paediatricians. It is
this apparent failure to differentiate between

BMJ VOLUME 299

12 AUGUST 1989

opinion and objective evidence and to foresee its

testing in the criminal court which has resulted in a
national furore over certain paediatric diagnoses
and is, perhaps, a symptom of the alarming decline
in the teaching of the basic principles of forensic
medicine in many medical schools in the United
Kingdom.2
STEPHEN LEADBEATTER
BERNARD KNIGHT
Subdepartment of Forensic Pathology,
University of Wales College of Medicine,
Royal Infirmary,
Cardiff CF2 lSZ
1 Meadow R. Suffocation and sudden infant death syndrome. Br
MedJ 1989;299:178-9. (15 July.)
2 Knight B, rhompson IM. The teaching of legal medicine
in British medical schools. Afed Educ 1986;20:246-58.

AUTHOR'S REPLY,-Dr Leadbeatter and Professor

Knight seem to believe that suffocation cannot be
proved without objective pathological evidence
and that, since there may be no findings at
necropsy in death by suffocation, such cases
cannot be proved. That is an extraordinary remark,
for there are many cases which have been proved in
criminal courts largely as a result of the mothers'
confessions. Has Professor Knight forgotten the
case in which he was involved, which was widely
reported in the national press on 9 January 1988?
The reports concerned the death of an 11 month
old boy claimed as a "cot death" whose necropsy
findings were "entirely consistent with cot death."
The mother was prosecuted, and despite Professor
Knight's evidence for the defence the jury accepted
the validity of the mother's confession and she was
given the usual sentence, for suffocation, of two to
three years' probation. Confessions are forming an
important part of successful prosecutions and your
correspondents' commefit that confessions "would
be an insufficient basis for successful prosecution"
is incorrect.
While it is right to investigate maternal confessions with circumspection, it is reckless to
disregard them and unwise to disparage them. It is
particularly inappropriate that Dr Leadbeatter and
Professor Knight should do so only a few days after
the publication of the official inquiry into the
horrific death at the hands of her parents of young
Doreen Mason in Southwark. (One of the criticisms
of the social workers concerned was that they paid
insufficient attention to Mrs Mason's statement
that she had smothered her first child, Karl, whose
death at 3 months had been recorded as a cot
death.) Forensic pathologists should feel neither
surprised nor guilty that they are not concerned
with many cases of suffocation. They know that
the necropsy signs may be negligible, and since
most of them do not have the opportunity to talk
to the patients or relatives, they are less likely
to diagnose it. The people who uncover it are
those who undertake laborious psychosocial

investigation of the families concerned, such as has

been done in the north of England by Emery'
and in Wiltshire by Oliver.2 Those who identify
suffocation before death has occurred are vigilant
clinicians who realise that the recurrent near miss
cot deaths or apnoeas are being caused by the
mother.'
I remain unconvinced that "sudden infant death
syndrome" is either a syndrome or a diagnosis. It is
a label that covers a multitude of causes-and one
or two sins.
Recognition of suffocation is worth while not
only to safeguard other children after the death of a
first but also, as I made clear in my original article,4
because many cases are associated with repetitive
suffocation, which is often recognisable before
brain damage or death has occurred. Fortunately
paediatricians are becoming aware of this and have
intervened successfully in at least seven cases this
year.
The plea for suffocation to be viewed primarily
in the context of the criminal court is most unwise.
In relation to child abuse court decisions are made
on the balance of probabilities. That is appropriate
and is similar to the way that doctors work in
relation to their patients. We have to take definite
action to investigate or to treat on a careful
judgment of the balance of diagnostic probabilities
and the risk to benefit ratio of our action. If we wait
until we establish a criminal court certainty of
"beyond all reasonable doubt" we jeopardise our
patients and, if they are children suffering abuse or
neglect, we may be too late, as the successive
inquiries into the appalling deaths of Jasmine
Beckford, Kimberley Carlile, Maria Colwell, and
Doreen Mason have shown. Nevertheless, bearing
in mind the serious, wide ranging implications of a
diagnosis of child abuse, most clinicians, social
workers, and also the courts ensure that the
balance ofprobabilities is heavily weighted towards
a positive diagnosis before intervrening.
I welcome Dr Leadbeatter's and Professor
Knight's plea for more forensic medicine teaching
in our medical schools. I too worry about the
current difficulties facing academic units of forensic
medicine. However, the main advances in recognising and managing child abuse have come
not from forensic medicine but from doctors,
psychologists, and social workers who spend time
dealing with troubled families; and the longer
one spends doing that the more one comes to
understand the range of abuse, including suffocation, that is inflicted on children.
ROY MEADOW
St James's Unliversity Hospital,
Leeds LS9 7TF
1 Emery J1, Taylor EM. Investigation of SII)S. N Engl 7 Med
1986;315: 1676.
2 Oliver JE. Successive generations of child inaltreatmenit: the
childrcn. Br3' Psychiatry 1988;153:545-53.
3 Rosen CL, Frost JD, Bricker T, Tarnow JI), Gillette PC,

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