The Role and Experiences of Responders Attending the Sudden or Unexpected Death of a Child: A Systematic Review and Meta-Synthesis

The infrequency of sudden deaths in infancy and childhood means that professionals have limited exposure, making it difficult to gain experience and feel confident in their role. This meta-synthesis aims to synthesise qualitative research on the experience of professionals responding to cases of sudden or unexpected death. A systematic literature search was conducted using Academic Search Complete, CINHAL, Embase, psycINFO, PubMed and Web of Science, identifying ten papers for inclusion. Studies were appraised and synthesized using the principles of meta-synthesis. Four superordinate themes were identified: perceptions of role, experience on scene, approaches to coping, and barriers to support. Findings suggest the way responders perceive their role and their experience on scene affect the approach taken to tasks and coping strategies used. The complexity of experience is often not acknowledged by responders or their colleagues. Experiences are compounded by cumulative factors which were expressed by different professional groups and across settings. Several barriers relating to workforce culture within organisations were identified, alongside the implications these have on staff wellbeing and the impact on bereaved families.


Introduction
The death of a child is a rare and potentially devastating experience. In 2019, 2,390 infant deaths (aged under 1 year) and 907 child deaths (aged 1 to 15 years) occurred in England and Wales (Office for National Statistics, 2021a). Seven percent of these deaths are collectively defined as sudden or unexpected deaths in childhood (SUDiC) (Office for National Statistics, 2021b). Causes of unexpected deaths can include road traffic collisions, sudden infant death, the unexpected death of a child with a life limiting condition, accidents, suicide, and homicide. The relative infrequency of SUDiC means that first responders, including police officers and ambulance crew have limited exposure, making it difficult to gain and consolidate experience and to feel confident and competent in their role.
In England, the child death review process became mandatory in 2008, where all incidents of child death, unexpected or otherwise, are reviewed by Local Safeguarding Children's Boards (Cabinet Office, 2018). Although there is clarity in the legal processes surrounding the sudden death of a child in England, no research has explored how responders first on scene to the death of a child experience their role, or on the impact of this on the families of deceased children. The emotional challenge of responding to such incidents is acknowledged by leaders in policing, committed to improving the support available to those who are exposed to child death, and improving the care and support that bereaved families receive at the point of care.
Despite our interest in the experience of police officers, due to the scant availability of published literature, this paper explores the experience of a range of professionals responding to sudden death, focusing on the initial point of contact, immediately following the notification of death.

Aim
To increase the understanding of how first on scene professionals experience the sudden and unexpected death of a baby, child, or young person, answering the question what is known about the role and experience of first on scene professionals responding to cases of sudden or unexpected death?

Design
In this review a meta-synthesis approach was used to integrate several interrelated qualitative studies to generate novel theoretical connections and in-depth understanding of the phenomenon (Zimmer, 2006). The systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA)  and Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) (Tong et al., 2012) guidelines, and used the framework by Lachal et al. (2017) to structure the meta-synthesis, outlined in Figure 1.

Method
Six databases (psycINFO, PubMed, Web of Science, Academic Search Complete, CINHAL and Embase) were searched in May 2021. Search terms are shown in  • Qualitative study design or narrative • Studies that explore the experience of those employed as police officers, first responders and emergency services personnel, involved in incidents of sudden or unexpected death, including suicide.
The following exclusion criteria were applied: • Papers written in languages other than English, to prevent translation bias.

Search Outcomes and Quality Appraisal
A total of 80 papers were identified from database searches and a further 13 identified through hand searching. Ten papers were included in the synthesis; the reasons for exclusion are recorded in the PRISMA diagram, shown in Figure 2. Papers were critically appraised using the Critical Appraisal Skills Programme (CASP) tool (Critical Appraisal Skills, 2018), focusing on the validity, results, and relevance of content. All authors were involved in quality assessing papers. The quality appraisal did not highlight any information that led to the elimination of papers.

Data Extraction and Synthesis
Data was extracted from the papers by all authors. Thematic representation was drafted by MT, modified on discussion with the remaining authors. Themes were arranged to demonstrate theoretical connections between findings, arranged into superordinate themes that describe the experience of those responding to cases of sudden or unexpected death. During analysis, a constant comparison strategy was used. Emergent themes were discussed and agreed, ensuring traceability of the development of themes. Findings Table 2 provides a summary of the papers included in the meta-synthesis. Experiences of professionals from a range of backgrounds were included in the review, including police officers, prison officers, fire fighters, those working in the ambulance service and nurses.
We have referred to these collectively as 'responders' throughout the paper. Four superordinate themes were identified, which describe elements of how responders respond to and experience incidents of sudden death: (i) perceptions of  Qualitative survey Bereaved parents appreciated the joint agency approach, especially for the information it provided about the cause of death. Many parents wanted more emotional support to be routinely provided. Most parents found the joint home visit helpful, but a small minority of mothers found this intensely distressing. In comparison to home visits when police visited death scenes without paediatricians, information was missed, and parents found these visits more upsetting.
Kyron et al.
Ambulance, fire and rescue, police and state emergency services employees Qualitative survey Police and emergency services personnel reported notably higher rates of suicidal thoughts and plans than the general Australian adult population. Perceptions of stigma regarding mental health conditions from others in the workplace, negative impact of work on one's private life and low meaning of work were associated with suicidal thoughts. Higher resilience and social support were associated with lower suicidal thoughts.

Laing (1994) Nursing
Opinion Recognises the emotionally traumatic impact of dealing with sudden death. discusses the reluctance to engage with support, particularly by experiences, 'overconfident and proud' members of staff. Discusses the personal impact of sudden death on professionals and the value of team debriefs on individuals and the team as a whole. (continued)

Qualitative survey
The experience of job-related strain including exposure to the suicide.
They described suppressing their distress, despite significant emotional impact. They were often the first professionals at the scene, and undertook varied and often conflicting roles, including negotiating with patients in crisis, informing individuals of the death of a loved one, preserving the body/potential crime scene, and dealing with the intense emotional reactions of bereaved individuals. Participants reported long-term, salient memories of these events; however, there was a reported lack of acknowledgment in the workplace that suicides may be traumatic and no guidance for staff on how to cope.
Peters et al. and responding to bereaved relatives following sudden death in emergency care. Recognises the need for professionals to be able to provide information sensitively and to express compassion and empathy. Suggests that team leaders should be aware of the emotional effects on colleagues who support suddenly bereaved relatives, take steps to ensure they can cope, and provide a calm and competent presence. Team leaders should also ensure this critical element of emergency practitioners' work is included in departmental training programmes and that staff can learn from more experienced colleagues.
Smith et al. the role of those first on scene, (ii) experience on scene, (iii) approaches to coping, and (iv) barriers to support. Figure 3 illustrates the relationship between superordinate and subordinate themes. Each theme is elaborated on, below.
Perceptions of the role of those first on scene. The infrequency of cases relating to sudden or unexpected death was highlighted recurrently across the literature (Burke, 2017;Peters et al., 2016;Rudd & D'Andrea, 2015), making confidence and competence hard to achieve (Garstang et al., 2017). Responders highlighted a strong sense of responsibility, recognising the enormity of their role and how it differs from the majority of their day-to-day work (Garstang et al., 2017;Peters et al., 2016).
Responders recognised the enormity of the loss experienced by families and felt intimidated by being around those who are grieving (Burke, 2017;Smith et al., 2016;Sweeney et al., 2018). This was juxtaposed with a sense of responsibility for justice (Garstang et al., 2017;Nelson et al., 2020;Smith et al., 2016;Sweeney et al., 2018), and pressure to identify any criminal offence or foul play that contributed to the death of the child (Garstang et al., 2017). Professional isolation was discussed by responders, who described a lack of knowledge, support and understanding from colleagues outside of the police, such as those working in the ambulance service and emergency department (Garstang et al., 2017;Nelson et al., 2020;Smith et al., 2016). The perceived lack of awareness of others meant that responders experienced a lack of support, preventing them from expressing the emotional demands of the role with colleagues outside of the police. Furthermore, responders perceived 'mental toughness' as a requirement of their role (Smith et al., 2016). Their hesitation to express worries with peers was discussed, as they perceived sudden death to be a routine part of their role (Rudd & D'Andrea, 2015), and associated feelings of worry and sadness as a professional weakness (Sweeney et al., 2018), preventing them from seeking peer or organisational support. Responders highlighted the relative infrequency of incidents relating to sudden or unexpected death, resulting in a reliance on protocol (Garstang et al., 2017;Peters et al., 2016), and a task-focused approach being taken (Scott, 2013). This is contrasted against other, more frequently encountered elements of their role, where responders feel more familiar and confident (Nelson et al., 2020;Scott, 2013). Responders highlighted the challenge of balancing conflicting demands on scene, namely protecting the scene itself and being sympathetic to the needs of the bereaved family (Garstang et al., 2017). This was made more challenging when the cause of death is uncertain to those on scene (Garstang et al., 2017).
Experience on scene. The experience of responders at the scene of a sudden or unexpected death can be divided into four subordinate themes, described below. There is a strong correlation between their lived experience and the perception of their role, as shown in Figure 2.
Offices described feeling unprepared to manage the scene, owing to the rarity of sudden or unexpected death (Garstang et al., 2017;Nelson et al., 2020) of a child and the emotional demand that the role requires (Garstang et al., 2017). The considerable legal and professional requirements of the role can feel daunting and incongruent with meeting the needs of the bereaved family (Garstang et al., 2017;Peters et al., 2016). Responders discussed perceptions of professional inadequacy, particularly around their ability to support a grieving family (Garstang et al., 2017;Sweeney et al., 2018). This was more frequently cited by junior responders with less experience of managing sudden or unexpected deaths (Garstang et al., 2017).
The experience of professional isolation led to responders experiencing disenfranchisement (Nelson et al., 2020), which intensified their experience of loneliness (Laing, 1994;Smith et al., 2016;Sweeney et al., 2018). Responders described having no one to turn to for support either within their own teams (Garstang et al., 2017;Smith et al., 2016), other than those professionals they were working alongside during the incident, or outside of work (Kyron et al., 2021;Laing, 1994;Nelson et al., 2020;Smith et al., 2016), other than their immediate family.
The emotional challenges of bearing witness to the painful grief experiences of bereaved family members were cited by responders in numerous studies (Garstang et al., 2017;Laing, 1994;Nelson et al., 2020;Peters et al., 2016;Smith et al., 2016). This was exacerbated further by a perceived lack of knowledge, skills, and experience in supporting bereaved people (Sweeney et al., 2018) and in balancing the provision of support and the need to preserve a potential crime scene (Garstang et al., 2017;Nelson et al., 2020), despite the lack of perceived need.
The above three components of experience at the scene combine to create a cumulative experience, where each individual element compounds the emotionally challenging experiences of responders dealing with the sudden or unexpected death of a child (Nelson et al., 2020). This increases the sense of professional discomfort and feeling unprepared to meet the expectations of the role (Garstang et al., 2017;Peters et al., 2016;Rudd & D'Andrea, 2015).
Approaches to coping. The most widely discussed method of coping surrounded a taskfocused approach to the role, describing a focus of responders on practice requirements of their role whilst at the scene of a death. Responders described protocol-driven practice that focused on the bureaucratic requirements of the care, led by a protocol (Garstang et al., 2017;Nelson et al., 2020). This, in part, is a requirement of the role; there are comprehensive legal and professional requirements of police officers at the scene of a sudden death, outlined in, for example (College of Policing, 2020; NPCC Homicide Working Group, 2021). Additionally, the unfamiliar nature of the role, due to the rarity of sudden death in children contributed to the rationale given by officers for a task-focused approach (Garstang et al., 2017). Compassionate detachment describes a task-focused approach with grieving relatives, providing responders with an emotional barrier, allowing the separation of 'what they were seeing and hearing from what they needed to do to function professionally both during and after the events' (Rudd & D'Andrea, 2015: 301). A range of strategies to avoid grief both on scene and following the incident were described (Garstang et al., 2017;Nelson et al., 2020;Rudd & D'Andrea, 2015;Scott, 2013;Smith et al., 2016;Sweeney et al., 2018), which were regarded as protective by responders.
Compassionate detachment or fatigue was described by responders as having weakened compassion for, and detachment from the situation (Rudd & D'Andrea, 2015). This was regarded by some as an occupational hazard (Sweeney et al., 2018) or part of the role, and stems from overexposure, disenfranchisement and feeling inadequate (Smith et al., 2016) when experiences heightened levels of emotional trauma, such as sudden death (Garstang et al., 2017;Rudd & D'Andrea, 2015). Compassionate detachment (Rudd & D'Andrea, 2015) was attributed to the cumulative effect of multiple incidents rather than as the result of a single event (Scott, 2013) and appeared to be compounded by not accessing support, either because it was not available, or owing to the stigma associated with doing so (Rudd & D'Andrea, 2015;Sweeney et al., 2018).
Barriers to support. Workplace culture was commonly discussed by responders, who described feeling inhibited from sharing their feelings (Kyron et al., 2021;Laing, 1994) surrounding emotional experiences. These included internal barriers, such as professional pride (Laing, 1994) and perceptions of expectations of "mental toughness" in front line roles (Kyron et al., 2021). Colleagues contributed to a perceived lack of support, describing the use of dark humour (Nelson et al., 2020) and a "culture dominated by silence and machismo" (Sweeney et al., 2018, p. 477), being used as coping mechanisms by many but which prevent some responders from being able to express feelings of concern, or to access help. Sweeney et al. (2018) discussed the culture of silence that exists within the prison sector, compounding the experience of professional isolation and disenfranchisement already discussed. A lack of training on the availability of services, self-awareness and how to support colleagues led to the perception amongst responders of a "culture of silence" being described by some responders (Garstang et al., 2017;Sweeney et al., 2018), and a lack of awareness of how to support colleagues, or themselves. Responders highlighted the lack of available support from peers or employers, accepting that dealing with emotionally challenging incidents such as unexpected death of children is part of the police offer role (Sweeney et al., 2018) and that not showing emotion (Sweeney et al., 2018) or sharing feelings (Laing, 1994) are an expected part of the role.
Responders recognised the need for change and described a will to access such services (Sweeney et al., 2018) but were unaware of how to do so within their organisations, or felt that in doing so, they would be seen as weak or less professional than their peers (Kyron et al., 2021). Despite some organisations providing support for responders, this was usually targeted to those who expressed a need for support, rather than to the workforce more generally. Responders highlighted the feelings of shame associated with declaring their mental health needs, and the stigma of doing so within their organisation (Kyron et al., 2021).

Discussion
The aim of this review is to conduct a meta-synthesis to describe the experiences of responders who attended to incidents of sudden or unexpected death. Ten papers met the eligibility criteria for inclusion, published between 1994 and 2021. Four superordinate themes where identified that highlight the experience of responders. The findings from this review suggest that the way responders perceive their role generally, and their experience on scene affect the approach taken to tasks and the coping strategies are used by responders. It also highlighted several barriers that relate to workforce culture and structures within their organisation. These prevent responders from accessing help and support from their employer or their peers, which further impacts on the ways that responders deal with the emotional challenge when dealing with sudden or unexpected deaths of children.
Responders perceive the role as being fundamentally different to those around them. Increasingly in recent years, professional roles across health and social care have become less siloed (King & Shaw, 2021) resulting from an increase in interdisciplinary practice (Schot et al., 2020) with practitioners working across traditional role boundaries as their scope of practice increases. Outside of the health sector, this is seen less commonly (Valentine et al., 2018). The nature of some professional roles, including police and prison officers (Franich et al., 2021;Harkin, 2018) and those in the ambulance and fire service (Murphy & Greenhalgh, 2018) often work unilaterally, reducing cohesion and interdisciplinary working. This in turn increases experience of professional isolation of individual responders.
The emotional impact of caring for deceased children and supporting recently bereaved families has been discussed in current literature (Butler et al., 2019;Hanna et al., 2020;Jonas et al., 2018). The importance of peer support and the availability of emotional support from employers, and the benefits of these to staff is recognised in the literature (Chang, 2018;Garrino et al., 2017). In this review, a perceived lack of available support from organisations and colleagues led to responders feeling disenfranchised, and unable to discuss the impact of bearing witness to the death of a child, or expressions of grief from parents and other family members.
Responders are likely to be exposed to numerous sudden and unexpected deaths as well as other potentially traumatic events during their career (Ainsworth, 2012;Becker et al., 2009;Foley & Massey, 2018). Foley and Massey (2018) note that despite the perception of these traumatic events being part of the job, frequent exposure can lead to significant mental health issues including depression and post-traumatic stress disorder (Greenberg et al., 2015). The cumulative effect of these elements of experience were exacerbated by the lack of available support (Gagnon, 2020;Mast & Gillum, 2018). The experience of responders feeling out of their depth is not uncommon (Edwards & Kotera, 2021;Puente-Fernández et al., 2020), owing to the infrequent exposure to such cases. The effect of this is for practitioners to seek means of self-preservation (Lumsden & Black, 2019), which can include reverting to their core roles. This phenomenon has been reported across a range of professionals, including nurses (Rajamohan et al., 2019), police officers (Nisar & Rasheed, 2020) and emergency services personnel (Janka & Duschek, 2018;Regehr & LeBlanc, 2017). The cumulative effects of such exposures, coupled with the perceived lack of appropriate professional assistance can lead to negative mental health outcomes, including (Berg et al., 2003;Carlson-Johnson et al., 2020;Griffin et al., 2010;Police, 2014).

Strengths and Limitations
This is the first published meta-synthesis of studies relating to the experience of responders first on scene to cases of sudden or unexpected death. Although elements of professional experiences relating to this have been described separately in published papers, the theoretical line of argument created in this paper offer a new interpretation of the experience of those responders first on scene, who respond to technically and emotionally difficult cases.
Only papers published in English were considered for inclusion in the review, which may have disregarded publications written in other languages. The multiprofessional perspective of this paper should be noted when considering the findings of this review. It should therefore be considered as stimuli for further research, rather than an end in itself.

Implications
This review highlighted the complexity of the experience of responders when first on scene at sudden or unexpected death of babies, children, and young people. Several authors highlighted the need for organisations to provide better support to responders following involvement in traumatic cases such as sudden or unexpected death. This will lead to responders feeling more supported in their role and enabled to support grieving families around the time of death, before the involvement of other services.

Recommendations for Research
A robust approach was taken to reviewing existing literature which led to the development of cross-study links and supposition. These should be explored in primary research. Research should focus on how individual professional groups experience their role in cases of sudden and unexpected child death. This should include emergency services personnel, specifically police officers and those in the ambulance service, as well as those working in acute health services.
Due to the scant availably of literature surrounding each professional group, the nuances of team structure and working practices were not reflected. Future profession-specific research should focus on how the organisation of professional teams impacts on the experience of responders.
Research on the experience of parents, and how the conduct of professionals first on scene affects their grief would further expand the knowledge base and would inform professionals about the needs of acutely bereaved families.

Conclusion
The complexity of the experience of professionals responding to the scene of a sudden or unexpected death is often not recognised or acknowledged by responders themselves, or their colleagues. The experience is compounded by a number of cumulative factors which were expressed by different professional groups and across settings. There are many factors that contribute to the experience of responders, including the relative rarity of such cases, and a perceived lack of support due to workforce cultures and the ability to access support. The role, experience and emotional support needs of responders need to be acknowledged and expressed, improving access to support, by reducing stigma and increasing self-awareness of professionals involved in responding to cases of sudden or unexpected death.

Acknowledgments
We would like to gratefully acknowledge Inspector Carol Kirk, North Yorkshire Police for contributing her time and to the Senior Investigating Officers who engaged in a discussion which led to this project.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship and/or publication of this article. degree at University of Bradford and is currently completed her MSc in professional practice. Prior to her current role, Sarah worked in the Emergency Department, acute safeguarding, and children's community clinics. Her clinical and research interests include safeguarding children, sudden and unexpected death in childhood, staff debrief, staff support in the emergency department, nursing children with acute illness and practice education support. You can follow Sarah on Twitter: @SLScholes Stuart Henderson (MA BSc (hons)) is a police sergeant with North Yorkshire Police and has been a serving police officer for 12 years. Prior to joining the police in 2010 he was a paramedic with Yorkshire Ambulance Service. For the majority of his policing career, Stuart has worked within a front-line response policing role, responding to sudden deaths and major crimes. Stuart has a master's in criminal justice, governance, and police science, completed at Ruhr University, Bochum, Germany. His professional interests include community cohesion, police education, hate crime, leadership, and police use of force.
Fiona Croucher (MSc BSc (hons) RNC RNA) is an assistant professor of children and young people's nursing in the School of Nursing and Healthcare Leadership at the University of Bradford. Fiona has 28 years of nursing experience, focusing on the acute deterioration of the child, physiological stabilisation and resuscitation. She is a European Paediatric Life Support Instructor for the Resuscitation Council (UK). Fiona's research interests include the effectiveness of paediatric early warning scores to identify deterioration in the hospital setting. You can follow Fiona on Twitter: @FiCroucher Carla Gibson (BSc (hons) RNC) is a lecturer in children and young people's nursing in the School of Nursing and Healthcare Leadership at the University of Bradford. She qualified as a children's nurse in 2008 and worked in a district general hospital, in both the neonatal unit and children's ward before moving to academia in 2020. Carla's clinical interests include the stabilisation of the acutely unwell child, initial assessment and management, and safeguarding children and young people. Her research interests surround support for staff following an untoward incident and the management of a mental health crisis in the acute setting. You can follow Carla on Twitter: @Gibson_Carla1