Inquest into the deaths of Kayla EWIN and Iziah O’SULLIVAN

Unknown·Kayla Ewin: Unascertained (SUDI 0+); Iziah O'Sullivan: Unascertained (SUDI 0)

Two infants died suddenly and unexpectedly at home with unascertained causes classified as SUDI (Sudden Unexpected Death in Infancy). Key clinical lessons include: improved documentation of scene temperature (relevant for hyperthermia assessment), completion of SUDI medical history forms by hospital staff (consistently missing, complicating autopsy interpretation), timely provision of scene photographs to forensic pathologists, and coordination between agencies. Family support was inadequate—parents felt under suspicion, lacked time with deceased infants, and experienced unnecessary police presence during grieving. System failures included incomplete medical histories (less than 50% provided to forensic pathologists), lack of standardised training for staff supporting bereaved families, and absence of early interagency clinical review meetings. Recommendations focus on standardising SUDI investigation procedures, improving family care protocols, ensuring complete medical documentation reaches pathologists promptly, and establishing centralised paediatric expertise available 24/7.