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Objectives: To determine the rate of sudden unexpected death in infancy (SUDI) for infants born after a previous SUDI in the same family, and to establish the causes of death and the frequency of child protection concerns in families with recurrent SUDI., Design: Observational study using clinical case records., Setting: The UK's Care of Next Infant (CONI) programme, which provides additional care to families who have experienced SUDI with their subsequent children., Patients: Infants registered on CONI between January 2000 and December 2015., Main Outcome Measures: Cause of death, presence of modifiable risk factors for SUDI and child protection concerns., Results: There were 6608 live-born infants registered in CONI with 29 deaths. 26 families had 2 deaths, and 3 families had 3 deaths. The SUDI rate for infants born after one SUDI is 3.93 (95% CI 2.7 to 5.8) per 1000 live births. Cause of death was unexplained for 19 first and 15 CONI deaths. Accidental asphyxia accounted for 2 first and 6 CONI deaths; medical causes for 3 first and 4 CONI deaths; and homicide for 2 first and 4 CONI deaths. 10 families had child protection concerns., Conclusions: The SUDI rate for siblings is 10 times higher than the current UK SUDI rate. Homicide presenting as recurrent SUDI is very rare. Many parents continued to smoke and exposed infants to hazardous co-sleeping situations, with these directly leading to or contributing to the death of six siblings. SUDI parents need support to improve parenting skills and reduce risk to subsequent infants., Competing Interests: Competing interests: All authors are members of the CONI national steering group managed by The Lullaby Trust. AW was funded by The Lullaby Trust as the national CONI coordinator from 1988 to 2015 and was employed by them from 2015 to 2018. AMc was funded by the Foundation for the Study of Infant Deaths/The Lullaby Trust between 1988 and 2013. All other authors received expenses only from The Lullaby Trust towards their CONI work but no salary. JJG has received research grants from the National Institute for Health Research (DRF 2010-0345)., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

The death of a child is a sentinel event in a community, and a defining marker of a society's policies of safety and health. Child death as a result of abuse and neglect is a tragic outcome that occurs in all nations of the world. The true incidence of fatal child abuse and neglect is unknown. The most accurate incidence data of such deaths have been obtained from countries where multi-agency death review teams analyse the causes of child fatalities, as is done in the United States and Australia.

It is impossible to be certain, but it is estimated that each year in England and Wales there may be about 30-40 infant deaths from covert homicide, which represents about 10% of the current annual total of sudden unexpected deaths in infancy. This paper reviews the features that have been suggested as possible indicators of covert homicide, describes the difficulties in its identification and the need for better evidence, and emphasises the importance of thorough medical investigation of all sudden infant deaths.