Recommendation 8: Sudden Unexpected Death in Infancy and Childhood (SUDIC)
From Thirlwall Inquiry Final Report, published 15 September 2026.
Recommendation
i. NHS England must:
a. Immediately inform all Trusts with a neonatal unit that the SUDIC process applies
to the sudden and unexpected deaths of babies who have never left hospital.
b. Direct all Trusts that they must, within seven days, draw this information to the
attention of all relevant staff and the Board.
ii. DHSC must complete its review and revision of the SUDIC guidelines and ensure
the revised guidelines are distributed to all Trusts by no later than 31 March 2027.
The guidelines must include a clear statement that SUDIC applies to sudden and
unexpected deaths of babies who have never left hospital.
iii. SUDIC forms must be redesigned and shortened to keep bureaucracy to a minimum.
The focus should be on what it is essential to know.
In brief (written by this site)
In September 2026, Duncan Burton and Sarah-Jane Marsh of NHS England instructed all trusts with a neonatal unit to communicate to relevant staff and their boards by 28 September 2026 that the SUDIC protocol applies to unexpected deaths within those units (Duncan Burton; Sarah-Jane Marsh, Sep 2026). In September 2026, Yvette Cooper confirmed that reviewing and updating the sudden unexpected death in infancy and childhood guidance was "now underway" (Yvette Cooper response, Sep 2026).
AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026. The record below is the sources' own words.
Government response
The inquiry says the sudden, unexpected death in infancy and childhood guidance must be updated. I agree. That is now underway.
Delivery
NHS England says in progress (22 September 2026)
Sudden and Unexpected Death In Children (SUDIC): The inquiry rightly made clear that no member of staff should ever assert that they did not know what to do in response to a sudden and unexplained death. The SUDIC protocol is applicable for every death (or collapse leading to death) of an infant or child under the age of 18 which would not have been reasonably expected to occur 24 hours previously and in whom no pre-existing medical cause of death is apparent, irrespective of the place of death. This includes sudden and unexpected deaths within neonatal units. All trusts with a neonatal unit must urgently communicate to all relevant staff and the board that the SUDIC process applies as set out above. This must be completed by no later than Monday 28 September 2026. It is important to note that SUDIC reporting runs alongside your own internal reporting processes.
From: Thirlwall Inquiry report and recommendations (letter PRN02660)
Site note: NHS England's letter to NHS trusts and integrated care boards (PRN02660), signed by Duncan Burton, Chief Nursing Officer for England, and Sarah-Jane Marsh, NHS England Chief Operating Officer. The letter bears no date; NHS England published it on 22 September 2026, and it calls the leadership event of 22 September "tomorrow". The passage is under the letter's heading "Actions needed now".
Responsible bodies
Who has spoken
- Department of Health and Social Care
Response - NHS England
Delivery statement