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Abstract
Introduction The Irish Office of the State Pathologist (OSP) provides a forensic pathology service for cases of criminal, suspicious or unusual deaths as referred by the coroner. This study aims to review the paediatric and perinatal deaths referred to the OSP and compare them to existing standards and data.
Methods A retrospective cohort study was conducted on all paediatric and perinatal cases (<18 years) referred to the OSP from 2018 to 2022. Postmortem examination (PME) reports were reviewed in line with the Royal College of Pathologists guidance. Case data results were then analysed independently and alongside previously published data for 2012–2017.
Results 65 cases were identified. Confirmed homicide accounted for the highest proportion of referred cases at 31% (n=20). Sudden infant death syndrome (SIDS) was the key cause under 1 years old (n=10/13). 91% of postmortem reports (2018–2022) met reporting standards. Paediatric and perinatal referrals remained consistent when comparing 2012–2017 to 2018–2022. Areas of inconsistency were in the area of SIDS and the inclusion of anthropometric reference values. PMEs involving forensic pathologists (FPs) and paediatric/perinatal pathologists (PPs) produced variations in reporting.
Conclusion Homicide was the leading cause of referred cases at 31% over 2018–2022 and 29% between 2012-2022. While the OSP provides a high standard service, key areas of improvement include the reporting of SIDS, the anthropometric reference values and the integration of PP and FP reports. Analysis of child mortality data and statistics in Ireland would be improved with the implementation of a single reporting database.
- Paediatrics
- Pathology
- Epidemiology
- Child Welfare
- Neonatology
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Ireland does not have a central reporting database for child mortality therefore this report is necessary to track outcomes and trends domestically and allow for international comparison.
It is also crucial to assess the quality of reported postmortem reports in line with expected standards.
WHAT THIS STUDY ADDS
Homicide accounted for 31% of referred cases between 2018 and 2022 while sudden infant death syndrome (SIDS) accounted for 77% of referred cases under 1 years old.
Referral numbers from the coroner were consistent between 2018–2022 and 2012–2017.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Postmortem examination reports should target improvements in classification of cases of SIDS, inclusion of normative values for organs, heights, weights and streamlining of reports with forensic and paediatric/perinatal pathologist involvement.
A single database for all Irish child mortality statistics is crucial to accurately capture data and decide interventions.
Introduction
The Office of the State Pathologist (OSP) in Ireland operates under the Department of Justice and provides continuous forensic pathology services across the country. Based in Dublin, the OSP is staffed by forensic pathologists (FPs), who are medical doctors specialised in forensic pathology. Their primary role is to conduct postmortem examinations (PMEs) in suspicious or unusual deaths as directed by 37 regional coroners covering 33 districts, often based on information from An Garda Síochána (AGS—the Irish police).1 Given the unique anatomy and causes of death in the paediatric and perinatal population, a paediatric/perinatal pathologist (PP) is involved in cases without obvious trauma and those suspected of involving non-accidental injury. This collaboration ensures comprehensive and specialised PMEs for this vulnerable group, supporting justice in potential cases of violence or abuse. This approach helps maintain high reporting standards.
Between 2018 and 2022, there were 907 total deaths under the age of 1 years old, 69 of those were classified as sudden infant death syndrome (SIDS) and 352 total deaths of children aged 1–14 in Ireland, according to combined data from reports by the National Office of Clinical Audit (NOCA), the Irish Department of Children and the Central Statistics Office (CSO).2–9 Ireland’s coroner service does not publish yearly data points; thus, it is difficult to estimate the total number of paediatric cases referred to the coroner between 2018 and 2022. A report by NOCA indicates that between 2019 and Q3 2024 up to 40% of child and young adult mortality cases in one of Ireland’s leading paediatric hospitals were referred to a coroner and that almost one-half required a PME.2 While NOCA has collated and provided statistics on child mortality data in Ireland since 2018, their report highlights that there is no national reporting database which provides adequate data on paediatric deaths as of yet in Ireland. This report referenced issues with the detail of content of PME reports as a potential limiting factor in populating such a database.9 Reporting on forensic child mortality in Ireland and auditing the method of reporting is therefore particularly crucial in the absence of standardisation.
This retrospective cohort study aimed to examine all paediatric/perinatal cases referred to the OSP over a 5-year period from 2018 to 2022 and then analyse those in conjunction with existing data points from the previous 6-year period as carried out by Eakins et al.10 The primary objective was to categorise each death, analyse them in conjunction with previous data and assess the PME processes and reports according to current best practice guidelines.
Methods
This study’s inclusion criteria were all cases of intrapartum, neonatal and paediatric deaths referred to the OSP by the coroner between 2018 and 2022. The paediatric age range was defined up to the last day of the 18th year. Cases referred to the OSP are those where there are suspicions around non-natural deaths as determined by the coroner. Cases of natural deaths or those where no suspicious circumstances are identified are not sent to the OSP and may be referred to a PP. These cases were not included in this study.
Data was collected from the OSP’s physical and digital databases and was securely stored on password-protected computers at the OSP in Dublin.
The four age ranges used to analyse data were perinatal cases (deaths occurring from 20 weeks’ gestation to 7 days ex-utero), infant deaths (from 7 days to 364 days old), 1–12 years old and 13–17 years old. In addition to providing a cause of death, all cases were categorised by the pathologist on completion of a PME report; ‘unascertained’ was assigned when there was no cause of death found at PME, while ‘unclassified’ was assigned in cases where there was a cause of death, for example, drowning or trauma, but the mechanism could not be determined at PME. The Royal College of Pathologists (RCPath) provides advisory frameworks on PME practices in the UK and Ireland, including neonatal, intrapartum and sudden unexpected death in infancy (SUDI) and childhood. PME reports from 2018 to 2022 were assessed for adherence to best practice standards in accordance with the relevant RCPath guidelines.11–13 Analysis was then conducted with published data from a similar audit of paediatric OSP cases between 2012–2017 by Eakins et al.10 SIDS is defined as per the San Diego definition; ‘the sudden unexpected death of an infant <1 year of age, with onset of the fatal episode apparently occurring during sleep, that remains unexplained after a thorough investigation, including performance of a complete autopsy and review of the circumstances of death and the clinical history’.14 Sudden unexplained death in childhood (SUDC) was defined as ‘the sudden and unexpected death of a child over one year of age that remains unexplained after a thorough investigation, including a complete autopsy, examination of the death scene, and review of the clinical history’.15
Cases were pseudonymised and inputted to Microsoft Excel. Data was presented using mean and percentages.
Results
65 paediatric/perinatal cases were referred in the study period. Perinatal and paediatric cases represented 7% (65/967) of the OSP total over all age groups.
54% of cases were male. The main referral reason was obvious signs of injury, 21 (32%) (figure 1). Of the 65, 54% (n=35) were referred from coroners outside of Dublin involving FP mobilising to regional sites (table 1). The spread of cases in counties outside of Dublin varied considerably; the next highest case numbers were in the Limerick region (n=8) and Cork region (n=4), respectively.
Reason for coroner's referral for all cases 2018–2022.
Case demographic characteristics of current 5-year auditing period (2018–2022) and previous 6-year audited period (2012–2017); gender, age ranges and reason for referral
Children aged 1–12 years predictably accounted for the largest proportion at 22 cases (34%). Teenagers aged 13–17 made up 15 cases (23%), as did perinatal deaths. Infants under 1 year of age (excluding perinatal deaths) comprised 20% of the cases.
Office of the Irish state pathologist findings
The case distribution revealed confirmed homicide, including non-accidental injury (n=2), accounted for the highest proportion of referred cases (n=20), while death from natural causes was the second highest (n=14). Case classifications were reported as per the FP’s PM reports (table 2).
Outcome of PME reports; classification of deaths 2018–2022
Perinatal cases (n=15)
Eight were deemed to be due to natural causes. Four cases were unascertained. One case associated with blunt force trauma was classified as non-accidental injury. Another case that cited abruptio placentae following blunt force trauma as the cause of death was categorised by the FP as unclassified, indicating that the mechanism could not be determined at PM. One case was due to maternal late termination. Four of the 15 were referred due to concealed remains.
Age under 1 year (n=13)
Homicide accounted for three cases; drug toxicity was involved in two, with one case being due to abusive head trauma. There were 10 cases classified as SIDS. Three cited co-sleeping as a likely risk factor, one prone positioning and one due to an overlaying blanket. The age range for cases of SIDS was 3 weeks to 11 months.
Age 1–12 years (n=22)
Homicide accounted for 13 (59%) of cases aged 1–12 years old; asphyxia (6), stabbing injuries (3), vehicle-related injury (2), blunt object injuries (1) and one case classified as non-accidental injury due to traumatic head injury. Eight cases of homicide were suspected to involve the child’s mother. Four further cases referred due to suspicious circumstances surrounding the death were found to be due to natural causes, with two as a result of systemic sepsis (group A streptococcus, respiratory syncytial virus) and one due to pneumonia (haemophilus influenza). One unascertained case was accounted for by SUDC.
Age 13–17 years (n=15)
Three cases were due to homicide (one each related to blunt object trauma, stab wounds and burn injuries). Accidents accounted for 40% of deaths (n=6). Five cases were deaths due to road traffic collisions. Four involved fatal non-prescription drug and alcohol use.
Case analysis in combination with the previous audited period
Combining exact data points of 2018–2022 with Eakins et al for 2012–2017 reveals a total of 144 cases were referred to the OSP over an 11-year period (2012–2022 inclusive).10 While the difference in reporting year spans and lack of individual yearly data make a direct comparison difficult, a collation of data points between the two sets allows for a broad overview of total cohort numbers (tables 1 and 3). When case numbers across the two periods are balanced with yearly averages, it can be seen that a consistent mean of 13 cases per year were seen over both periods (n=79 cases/6 years vs 65 cases/5 years). Homicide was found to be the leading outcome in both reporting periods and accounted for 29% of referred cases. Accidents remained the most commonly reported cause of death in the 13–17 years old group in both periods (14 out of 35, 40%). Perinatal deaths referred to the OSP were deemed to be due to natural causes in 74% (20/27) of referred cases over the 11-year period.
Outcome of PME reports in 2012–2017 and 2018–2022 with 11-year totals
PME processes and reports according to current best practice guidelines
From 2018 to 2022, 59/65 (91%) cases complied with RCPath reporting criteria.11–13 This included 10 cases designated as SIDS and one as SUDC; reporting criteria regarding the listing of risk factors were increasingly implemented in more recent years, but five of the 10 cases did not list risk factors for SIDS. Normal ranges or percentiles for organ weights were intermittently included by the PP’s. In 34 out of 36 relevant cases, there was a PP and an FP present, which is in line with best practice findings from a previous audit. In the two remaining cases, there were two FPs present at the PM. Where the PP was involved, the method of integration of the FP report and PP report was variable.
Discussion
This study identified paediatric and perinatal deaths referred to the OSP, Ireland, over a 5-year period. Homicide continued to make up the highest outcome of all referred cases in the most recent 5-year period (31%), as was the case in the preceding report between 2012 and 2017 (27%).10 In the context of our results for 2018–2022, we can see that out of 907 total cases of mortality of those under 1 years old, the coroner referred 3% of 907 (n=28) to the OSP and 0.33% (3/907) were then classified as homicide. As for 352 total deaths of children aged between 1 and 14 years old, 7% (26/352) were referred to the OSP and 4% (14/352) were deemed to be due to homicide.2–9
From 2018 to 2022, the child’s mother was suspected to be the perpetrator in 67% of homicide cases between aged 1 and 12 years (8/12). In each case of homicide involving the child’s mother, the mother’s mental health issues were noted. The main cause of death in these cases was asphyxia by ligature or smothering, while three other cases of sharp wound trauma were suspected to involve non-paternal male perpetrators. These gender-based differences in homicide methods are trends also seen in analysed UK and Australian case reviews.16 17 Case numbers in this report period are small; however, these findings clearly signal a need for further research and action into the mental health and social support for parents, and in particular mothers. It is worth noting that there was only one infant abusive head trauma (shaken baby syndrome) case, lower than international estimates. The international incidence of abusive head trauma is unknown due to difficulties in diagnosis, but a 2023 report in the USA estimated the incidence to be 35 out of every 100 000 infants and fatal in 5–35% of these cases.18
This report shows that out of the total 69 cases of SIDS reported by the CSO for 2018–2022, only 15% (10/69) were deemed to require a referral to the OSP due to suspicious circumstances.3–8 SIDS was found as the main cause of death in referred cases under 1 year of age from 2018 to 2022 (n=10, 77%), but it is worth noting that the overall numbers of SIDS/SUDI in Ireland have declined in recent years.2 Efforts are being made to define key risk factors and reduce ambiguity, such as the triple risk model of intrinsic, extrinsic and critical time factors put forward by Filiano and Kinney.19 PME reports from 2018 to 2022 showed that risk factors for SIDS were alluded to in histories in 5 out of 10 cases but only 3 out of 10 clearly outlined these as contributing risk factors in the FP summary. One intrinsic hypothesis for SIDS is that unexplained cases may be due to genetic factors, although it was not found to be of significance in the most recent study period.20 Genetic microarray testing was carried out for unexplained cases of SIDS, with an unknown proportion having whole genome sequencing (from international laboratories). Extrinsic factors such as parenting capacity or poor socioeconomic status are associated with an increased rate of cases of SIDS but are difficult to identify by the FP in their PME reporting.19 21 This could be rectified by following the results of a UK study on best practice methods for SIDS investigation, which found that a trained healthcare professional such as a public healthcare nurse or paediatrician at the death scene would most efficiently capture a full medical history including risk factors.22
The relatively small paediatric caseload (7% of the OSP’s total caseload) emphasises the difficulty for the FP to maintain their expertise on this unique cohort. This validates the standard practice of enlisting experts who are regularly involved in this area (PPs) to collaborate on appropriate cases and standardised reporting which occurred in 34 out of 36 relevant cases.10 A lack of uniform reporting was found when PP’s and FP’s worked together, however. For example, demographic data and weights were carried out by the PP’s and were included in every report, but normative reference values such as height, weight and organ weight were only intermittently included. The significance of PME figures in the absence of quoted normative values can be difficult to discern, and therefore the standard reference ranges, such as those put forward by Molina et al, should be agreed on by FP’s and PP’s.23 A future standardised report with subsections for each pathologist would avoid duplicating or omitting information.
There is no centralised recording of child death and coronial data in Ireland, which creates a limitation in this study’s ability to accurately put our data points in the context of population-wide statistics and compare internationally. NOCA via the National Paediatric Mortality Register (NPMR) has compiled valuable data on child mortality deaths in Ireland. However, these reports rely on multiple data sources which are hindered by delayed reporting of child mortality.2 9 Important case data, such as exact numbers of SIDS cases and their risk factors, for example, are unlikely to be fully accurate in the absence of a standardised method of online reporting that is mandatory for all pathologists throughout Ireland, including the OSP. Improvements in data standards should be sought by modelling after international online case reporting systems like the National Fatality Review-Case Reporting system in the USA and the National Child Mortality Database in the UK. Fortunately, the NPMR is in the process of piloting a standardised reporting form in paediatric hospitals throughout Ireland.2 While this pilot phase does not yet include coroner cases, future reports could adopt their datapoints until national implementation of this online database.
Overall, paediatric and perinatal case numbers referred to the OSP remained consistent when comparing the average number of cases per year between 2012–2017 and 2018–2022. Perhaps predictably, homicide was the leading cause of death overall at 29% between 2012 and 2022. Maternal mental health was a key factor in 67% cases of homicides aged 1–12. Relevant cases involving a PP should use a standardised joint PME report, and all cases should aim to work towards standardised reporting as per NPMR aims. Adherence to PME standards is high but could be improved by referencing normative anthropometric/organ values as standard. Extrinsic risk factors are best captured by a specialised healthcare professional at the scene, while future PME reports should clearly outline the medical risk factors in cases of SIDS in addition to established autopsy findings. This study further highlights the need for a single streamlined source for child mortality data in Ireland.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Footnotes
Contributors DM carried out the data collection, analysis and manuscript write up and takes responsibility for the overall content as the guarantor. MJB contributed to the manuscript synthesis and drafting. HO was responsible for supervision during the study and contributed to manuscript drafting. LM was responsible for the study design and contributed to manuscript drafting.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests MJB is chair of the National Paediatric Mortality Register at the National Office of Clinical Audit, Dublin.
Provenance and peer review Not commissioned; externally peer reviewed.