Closed consultation

Coronial investigations of stillbirths: factual summary of consultation responses

Updated 7 December 2023

Ministerial foreword

Every stillbirth is a tragedy, and we remain absolutely committed to supporting parents during such a difficult time. Losing a loved one is one of the most difficult things we can go through. That is why one of this government’s highest priorities is to reduce stillbirths and other adverse maternity outcomes, and make sure that grieving families and friends have access to the support they need.

As part of this, we are working to improve the information available to families regarding the investigative processes that may take place following a stillbirth. Additionally, we are committed to ensuring that, wherever possible, we do all we can to ensure that, when such a tragedy occurs, lessons are learned and changes are made to prevent avoidable stillbirths in the future.

We would like to thank everyone who took time to contribute to the public consultation and stakeholder workshops on proposals on whether coronial investigations of stillbirth cases could take place in England and Wales and, if so, how.

We received 334 responses to the consultation and 63 people attended our stakeholder workshops. We are extremely grateful to those who responded and shared their views, particularly from families who had experienced stillbirth and shared their tragic, personal experiences; this was so important to us in considering our response. 

It is essential that we get this right, given the emotional impact that losing a baby has on parents and others involved. Work to publish our consultation response was paused during the pandemic. The findings of the consultation were complex and, given the nature of the issues raised, it is imperative that all responses are carefully considered when deciding whether the coronial jurisdiction should be extended to include the investigation of stillbirths. Respondents both supported and were against proposals that coroners should have a role in stillbirth investigations. Some respondents were supportive of coroners having a role, but were not necessarily supportive of the way in which coronial investigations would be carried out.

Our response to the consultation at this time is therefore a factual summary of the received responses. Going forward, the Department of Health and Social Care (DHSC) and the Ministry of Justice (MoJ) will work together to explore the issues raised by consultees. Upon full consideration, a further statement will be issued that sets out whether and, if so, how coroners will investigate stillbirths.

Maria Caulfield, Parliamentary Under Secretary of State at the Department of Health and Social Care

Mike Freer, Parliamentary Under Secretary of State for the Ministry of Justice

Executive summary

Over the years, there have been calls from bereaved families, charities and others for a more transparent and independent process for determining the causes of, and learning from, stillbirths. Some of those calling for change identified coronial investigations as the way to deliver an improved process.

On 26 March 2019, MoJ and DHSC published a consultation seeking views on proposals for introducing coronial investigations of stillbirth cases in England and Wales.

The objectives of the proposals, which were co-developed with stakeholders, were to:

• bring greater independence to the way stillbirths are investigated
• ensure transparency and enhance the involvement of bereaved parents in stillbirth investigation processes, including in the development of recommendations aimed at improving maternity care
• effectively disseminate learning from investigations across the health system to help prevent future avoidable stillbirths

Two consultation documents - a longer and shorter version - were published. Four stakeholder workshops were held across England and Wales to discuss the consultation, involving 63 attendees spanning the full range of stakeholder groups. There were 334 written responses to the consultation.

Findings

Some respondents were supportive of the proposal for coroners to have a role in investigating stillbirths. However, many of those same respondents did not agree with the proposed way in which coroners would conduct their investigations. For example, they caveated their support because of concerns about:

• no facility for parental consent to coroner’s investigations, citing a range of concerns including:
  • that the mandatory nature of the investigations could be distressing and intrusive
  • their public nature
  • the loss of parental control over whether a post-mortem examination would take place
• the potential length of the inquest process
• the need for assurance that people would not be blamed for their actions during pregnancy (for example, smoking while pregnant)

Coronial jurisdiction is established in statute, which sets out the circumstances in which an investigation must be undertaken. The coroner does not have discretion as to whether or not to investigate a death that meets the statutory criteria, and the consent of interested persons - such as the family of the deceased - is not required. Our proposal was that this would similarly apply in investigations of stillbirths.

Furthermore, many key issues were identified, including:

• the potential for duplication (and interaction issues) between investigations by the coroner, the Healthcare Safety Investigation Branch’s maternity investigation programme (which is now the Maternity and Neonatal Safety Investigations programme), and the relevant trust or health board, which could have a knock-on impact for clinician behaviours or culture and could lead to confusion where different investigations make conflicting findings. It was noted that the investigatory processes introduced in 2018 would achieve the same policy objectives as coronial investigations
• the impact on resources for coroners, local authorities (which resource and fund local coroner services) and the NHS (for example, midwives and other clinical staff may be diverted from frontline care to participate in coroner inquests, and funding for frontline services may be redirected towards covering legal costs)
• that there would be a significant increase in demand on paediatric pathology services, with a significant lead time needed to train sufficient practitioners to meet this
• concern that, in many cases:
  • it is difficult to establish how a stillbirth occurred
  • the process could give false hope to bereaved parents that answers could be found
  • coroners are not best placed to identify and disseminate clinical learning points

While there were many who acknowledged that coroners could deliver on this, there was no consensus on precisely how they would do so, and some strong opposition to the specific proposals we put forward.  

Conclusion

We recognise that losing a baby can significantly impact on parents’ and others’ lives, and therefore have carefully considered all the responses to this consultation.

The landscape of maternity investigations has changed significantly since publication of our consultation. From April 2019, the Healthcare Safety Investigation Branch’s Maternity Investigations Programme was fully established in all 122 NHS trusts and 11 ambulance services delivering and supporting maternity services in England. The purpose of the programme is to:

• provide independent, standardised and family-focused investigations for families
• provide learning to the health system through reports at local, regional and national level
• analyse data to identify key trends and provide system-wide learning
• be a system expert in standards for maternity investigations
• collaborate with system partners to escalate safety concerns

All families who give consent are contacted. Of the families who consented during the 2022 to 2023 financial year, 86% agreed to participate and 14% declined further participation in an investigation. In October 2023, the renamed Maternity and Newborn Safety Investigations programme moved to be hosted by the Care Quality Commission (CQC). This programme will be referred to as MNSI in the rest of this document.

Within Wales, the Maternity and Neonatal Safety Support Programme (MatNeoSSP) was commissioned during 2022 to ensure national work was undertaken to lead an all-Wales improvement approach, and maximise the opportunity for learning from independent reviews of maternity and neonatal services to improve outcomes for all women, babies and their families in Wales. It also focuses on patient and staff experience: an important triangulation in the assessment of performance.

Additionally, the Perinatal Mortality Review Tool (referred to here as the PMRT) supports standardised perinatal mortality reviews across NHS maternity and neonatal units in the UK. Over 18,000 reviews had been started and/or completed between the launch of the PMRT in January 2018 and February 2022. During 2021, a review of care was started for 96% of all babies who died in the perinatal period, comprising 97% of stillborn babies and those babies who died as between 22 to 23 weeks’ gestation, and 94% of babies who died in the neonatal period (first 4 weeks after birth). Overall, 95% of UK parents were told that a review of their care and that of their baby would take place, and 99% of these parents were asked for their own perspective about their care. This enables parents’ perspectives to be incorporated in the review and for any questions and concerns they have about their care to be addressed as the review proceeds and fed back to them at their post-bereavement consultant visit.

While greater independence, transparency and family involvement are more integrated into safety improvement initiatives, incident reviews and investigations, the consultation also indicated the consensus among stakeholders for an independent process, which is not led by an NHS organisation, to identify the causes of individual stillbirths and share the learning with all maternity service providers.

Our consultation response provides a factual summary of the responses received to the consultation. DHSC and MoJ, in partnership with Welsh Government counterparts, will review the issue further, carefully considering the issues identified by consultees and the effects of the initiatives now in place, such as the MNSI programme and the PMRT. A further statement will be issued in due course, to set out whether and, if so, how the coronial investigation of stillbirths will be taken forward. 

Background

Every year, thousands of babies are safely delivered to delighted parents by experienced and dedicated NHS staff. This is the outcome that all families expect and most families experience.

However, the tragedy of a stillbirth still occurs and, when it does, it has a profound effect upon the families who are bereaved by it. Therefore, we are committed to learning all we can when such a tragedy occurs and to improving care to prevent avoidable stillbirths in the future.

The National Maternity Safety Ambition is to halve the 2010 rates of stillbirths, neonatal and maternal deaths and brain injuries occurring during or soon after birth by 2025. An additional ambition is to reduce the pre-term birth rate from 8% to 6% by 2025.

We are making good progress in reducing adverse outcomes for mothers and babies. Since 2010, the stillbirth rate has reduced by 19.3%, and the neonatal mortality rate for babies born over the 24-week gestational age of viability has reduced by 30%.  

In September 2023, MBRRACE-UK’s Perinatal Mortality Surveillance report on UK perinatal deaths for births from 1 January to 31 December 2021 reported that perinatal mortality rates, including rates of stillbirths, increased across the UK in 2021 after 7 years of year-on-year reduction, highlighting the importance of ongoing work to reduce perinatal mortality.

In 2016 and 2017, DHSC worked collaboratively with clinical and academic experts to publish 2 documents:

• an action plan, Safer maternity care: next steps towards the national maternity ambition (2016)
• a refreshed maternity strategy, Safer maternity care: progress and next steps (2017)

Additionally, a range of safety initiatives have been rolled out since 2016, including a revised version of the Saving Babies Lives Care Bundle (2019), which includes a specific focus on pre-term stillbirth prevention.

While many bereaved parents have been satisfied with how NHS services have reviewed and investigated the causes of stillbirths, some have raised concerns about the inconsistency and independence of those investigations. This has led to calls for a more transparent and independent process for determining the causes of, and learning from, stillbirths.

Coroners have, for many years, investigated deaths where there have been concerns that the death was not from natural causes. They have the confidence of the public, and some bereaved parents, charities and others have suggested that their statutory responsibilities should be extended to stillborn babies and not limited to those who are born alive. 

In November 2017, the government announced its intention to consider whether and how coroners could carry out investigations into babies who are stillborn at term - that is at 37 weeks’ gestation and over.

On 26 March 2019, MoJ and DHSC published a consultation seeking views on proposals for introducing coronial investigation of stillbirth cases in England and Wales. The objectives of the proposals were to:

• bring greater independence to the way stillbirths are investigated
• ensure transparency and enhance the involvement of bereaved parents in stillbirth investigation processes, including in the development of recommendations aimed at improving maternity care
• effectively disseminate learning from investigations across the health system to help prevent future avoidable stillbirths

The consultation, including a short version document, was published and 4 stakeholder workshops were conducted across England and Wales involving 63 attendees and a wide range of stakeholder groups, including bereaved parents, charities, the (then) Chief Coroner and coroners, clinicians, MoJ and DHSC arm’s length bodies (ALBs), the Healthcare Safety Investigation Branch (HSIB), the Welsh Government, academics and the Royal Colleges.

Concurrent with the government developing its proposals, Parliament passed the Civil Partnerships, Marriages and Deaths (Registration Etc) Act 2019. Section 4 of this act places a duty on the Secretary of State to make arrangements for the preparation and publication of a report on whether and, if so, how coroners should investigate stillbirths. The act also provides a power for the Lord Chancellor to make provision, through secondary legislation, for stillbirth investigations by coroners if, following publication of that report, this is considered appropriate.

The government’s commitment to consider whether and how to introduce coronial investigations of stillbirths was announced as part of the refreshed maternity strategy (2017), which also set out a programme of initiatives to improve safety in maternity care. This included initiatives focused on improving the standards and quality of investigations and learning from serious incidents leading to stillbirth, including addressing issues such as:

• the independence of investigations
• the transparency of investigations
• the involvement of parents
• the dissemination of learning

New measures introduced are outlined below.

The Perinatal Mortality Review Tool (PMRT)

In early 2018, the PMRT was introduced to support NHS maternity and neonatal units in England, Wales and Scotland to undertake high-quality standardised reviews of the circumstances and care leading up to and surrounding all stillbirths and neonatal deaths.

From 2019, the PMRT has been incorporated in maternity services across the UK. The fourth annual report, Learning from Standardised Reviews When Babies Die, published in September 2022, presents an analysis of data from the 4,199 reviews completed between March 2021 and February 2022. Between the launch of the PMRT in early 2018, over 18,000 reviews have been started and/or completed using the tool.

Using the PMRT, the trust or health board can identify learning to prevent future deaths and improve local care by generating action plans that focus on system-level changes, and by combining the findings and learning from individual reviews into reports at the trust or health board level. Annual reports, such as the most recent, ‘Learning from Standardised Reviews When Babies Die’, combine findings from individual reviews and generate national-level recommendations for improvements in care.  

National reportable incidents

National reportable incidents (NRI) within Wales are reported to the NHS Wales Delivery Unit who oversee the learning from these.

While not all these incidents result in significant harm, exploration allows learning to be undertaken, while identifying emerging risks. It also provides a mechanism for oversight and assurance particularly where significant harm has occurred. All maternal, perinatal and infant deaths are reported and investigated via this mechanism.

Maternity and Newborn Safety Investigations (MNSI) 

From April 2018 to September 2023, the Healthcare Safety Investigation Branch was responsible for all NHS patient safety investigations of maternity incidents in England that met the criteria which were originally part of the Royal College of Obstetricians and Gynaecologists’ ‘Each Baby Counts’ programme. These include all term babies born following labour (at least 37 completed weeks of gestation) who have one of the following outcomes:

• intrapartum stillbirth
• early neonatal death
• potential severe brain injury

In addition, maternal deaths are also investigated where women die while pregnant or within 42 days of the end of their pregnancy.

The purpose of this programme is to achieve learning and improvement in maternity services, and to provide a driver for necessary system-wide change. The programme completed 702 reports in the 2022 to 2023 financial year and made more than 1,380 safety recommendations to trusts, addressing a wide range of issues during this time.  

As of October 2023, the programme became known as the Maternity and Newborn Safety Investigations (MNSI) programme and is hosted by CQC.

Coronial investigations into stillbirths: summary of responses

Consultation analysis methodology

We would like to thank everyone who took time to contribute to the public consultation and stakeholder workshops on proposals as to whether coronial investigations of stillbirth cases could take place in England and Wales and, if so, how.

We received 334 responses to the consultation, which comprised 295 responses to the long consultation document and 39 responses to the short consultation document. We held 4 stakeholder workshops involving 63 attendees across England and Wales covering the full range of stakeholders.

Table 1 shows a breakdown of the number of respondents who answered the consultation by stakeholder group. The total number of stakeholders does not equal the number of unique responses as respondents sometimes fell into more than one stakeholder group - for example, if a respondent was a bereaved parent but also a midwife.

The 63 roundtable attendees are not included in the breakdown of respondents below, but information gathered from the roundtables has been included in the summary of responses. Analysis of respondents’ answers by question is set out in the annex.

Table 1: breakdown of respondents by stakeholder group

Stakeholder group	Total
Bereaved families	142
General public	30
Other medical or allied health professional	30
Midwives	26
Obstetricians or gynaecologists	24
Legal profession	18
Charities	14
Coronial services	12
Pathologists	9
Health non-clinical	7
Academics	7
Paediatricians or neo-pedologists	4
Faith groups	3
Regulators	1
Police	1
Unknown	21

Note: the total number of stakeholders does not equal the total number of responses (334) as respondents sometimes fell into more than one stakeholder group.

Consultation documents

The consultation is available online, including:

• the full consultation document, which provides additional detail on the proposals as set out in the consultation
• a Welsh language version of the consultation
• a short version of the consultation documentation

Chapter 1: the need for coronial investigations

This chapter considers the gaps in current processes for investigating unexpected stillbirths that could potentially be filled by coroners.

Some respondents supported the principle of coroners investigating stillbirths:

• due to wanting to understand the cause of a stillbirth or the reason why a stillbirth occurred
• due to a desire to help to improve maternity services and prevent avoidable stillbirths happening in future
• for the purposes of ensuring greater transparency and independence of investigations

Some respondents noted that they themselves or family members had received an unsatisfactory investigation or that current investigative processes were not resulting in improvements.

A bereaved family member said:

I feel it is important for parents to feel completely confident that the investigation is run by someone completely unbiased and impartial, especially when there is concern there may have been substandard care.

However, some respondents had concerns about the way in which coroners’ investigations would be conducted. For example, they caveated their support for the principle of coroners investigating stillbirths as follows:

• the need for parental consent for coroners’ investigations, citing a range of concerns including that mandatory investigations would be public, distressing and intrusive, and the loss of parental control over whether a post-mortem examination would take place
• the need for the inquest to be concluded quickly. Many respondents were concerned about the potential for delays to coronial investigations, which could have a profound emotional impact on families. There was also concern that women might delay future pregnancies while waiting for the conclusion of an investigation, or that delay might put undue stress on a woman and her family if she is already pregnant. Additionally, if notes are retained by the coroner during the investigation, maternity teams may be unable to access medical records and information regarding the pregnancy that resulted in the stillbirth, potentially limiting the care clinical professionals can offer
• the need for assurance that people would not be blamed for their actions during pregnancy (for example, smoking while pregnant)

There were several key issues identified, including:

• the potential for duplication (and interaction issues) between coroner investigations and HSIB and trust or health board clinical investigations, which could have a knock-on impact for clinician behaviours or culture, and could lead to confusion if clinical reports have different findings from coroner investigations. It was noted that the MNSI programme and the PMRT would achieve the same policy objectives as coronial investigations
• the impact on resources for coroners, local authorities and the NHS - for example, midwives and other clinical staff may be diverted from frontline care to participate in coroner inquests, and funding for frontline services may be redirected towards covering legal costs
• that there would be a significant increase in demand on paediatric pathology services, and a significant lead time needed to train sufficient professionals to meet this

Some respondents said that coronial investigations into stillbirths would achieve the policy objectives. However, some respondents caveated this with the conditions outlined earlier in this chapter.

Respondents proposed that:

• bereaved families should be at the ‘heart of the investigations’
• communication with bereaved families should be maintained throughout the coronial investigation
• the family’s distress should be minimised as much as possible - for example, by providing enhanced support for parents during an inquest

There was concern that, once a judicial investigation was commenced, organisations would become defensive, and the expected open communication would therefore be compromised.

A bereaved family member said:

The principle objective should be support of the bereaved parents. Stillbirth is a unique and personal situation, and needs to be treated and assessed in a sensitive and personal manner.

Some respondents said that coronial investigations into stillbirths would not meet the policy objectives for the following reasons:

• the coronial investigation would not necessarily ensure good communication with the parents at every stage of the process
• concern that coroners do not have the required medical expertise to establish the cause for a stillbirth or the reason why a stillbirth occurred
• it was unclear how the learning would be disseminated effectively to contribute to wider learning

Some respondents suggested that other investigation processes that have been established and become operational over the last few years, such as use of the PMRT and MNSI programme, are already meeting the policy objectives, including increased family involvement.

An obstetrician said:

There are already systems in place to address this and 2 initiatives, Each Baby Counts and the recent MNSI programme system, which are already in addition to hospital investigation and incident reports…

Chapter 2: duties of the coroner and investigation outcomes

This chapter explores the duties of the coroner and the potential outcomes from coroners’ investigations. It considers the questions of what coroners could be asked to determine, and how coroners could disseminate any learning points and recommendations.

Some respondents supported the proposals for the determinations and recommendations to be made by coroners, and emphasised the importance of ascertaining ‘how’ it was that the baby was not born alive and ‘when’ the baby died in order to help families understand what happened.

However, other respondents noted the following issues:

• that, in many cases, it is difficult to establish how a stillbirth occurred, and exactly when and where a stillborn baby died (particularly for antepartum stillbirths). There was concern that the process could give false hope to bereaved parents that answers could be found
• that coroners were not best placed to make these determinations and would need to rely on medical professionals
• that ascertaining when fetal death occurred could result in mothers being blamed for their actions while pregnant - for example, smoking while pregnant

An academic said:

I think there could be issues with grieving women feeling blamed and stigmatised, if death was ‘officially’ assessed as happening at home or outside medical care, because there could be a sense that they were responsible for it.

Some respondents said that coroners should identify learning points and have a role in promoting best practice in antenatal care. Respondents who agreed suggested that a range of different organisations and parents should have access to the learning points. They also considered that it should be possible to identify national trends, including high occurrence of stillbirths in an area or with a trust or health board, or to identify good practice in areas with low levels of stillbirth.

However, other respondents were concerned about coroners not having the correct expertise to identify learning points or have a role in promoting best practice in antenatal care with no formal learning or experience in obstetrics, midwifery, maternal or perinatal pathology. It was suggested that it would be better for learning points and/or best practice to be determined via discussions between collaborative clinical multidisciplinary teams.

A coroner said:

The proposal of ascertaining how it was that the baby was not born alive does not require a coroner’s inquest. It requires a skilled senior obstetrician to undertake a review of the case, consider the case notes, speak to those involved and then make recommendations.

Some respondents were unsure how coroners would disseminate learning and suggested that the current process of using Prevention of Future Death reports would not be adequate to meet the policy objectives. In particular, coroners, by law, only investigate deaths in their local area rather than drawing inferences at a national level.

There was concern:

• regarding duplication of work and potential overlap
• that stillbirth cases are already reviewed and learning points generated as part of investigations by the NHS trust or health board via the PMRT and MNSI programme
• that another investigation would be unhelpful

A common suggestion was that coroners should not only ascertain who the mother of the stillborn baby is but the father too, to:

• provide equality and inclusivity for fathers
• identify any genetic issues linked to the reason why the baby was stillborn
• avoid the sole focus being on mothers who therefore feel they are to blame

A pathologist said:

What about fathers? They already feel side-lined in maternity care. It’s unfair to just consider mothers in cases of stillbirth - fathers have lost their baby too.

It was also suggested that care must be taken when it comes to ascertaining the baby’s name (which the coroner would be under a duty to do), particularly when the parents do not wish to give the baby a name.

In response to ‘do you think anything else should be considered?’, respondents suggested that, in their investigation, coroners should consider wider information about the parents (including surrogate parents) and the family unit (children and grandparents) of the baby when making their determinations. Suggestions for information that should be considered included:

• any background information on parents, such as relevant medical history, social or health factors - for example, use of drugs, medication or alcohol
• any information about the donor egg, if applicable
• any information about the mother’s previous pregnancies or stillbirths
• information regarding the mother’s antenatal care, including information of all scans, details of the hospital’s policies and procedures, use of equipment by clinicians, and names of the clinical team who provided care

Chapter 3: procedures and links with non-coronial investigations

This chapter considers the procedural aspects of a coroner’s investigation, including the sequencing between coronial and non-coronial investigations.

Some respondents agreed that, in line with how coroners investigate deaths as set out in statute, no consent or permission from the bereaved parents, or anyone else, should be required for a coronial investigation into a stillbirth to be opened, for the following reasons:

• to get the required answers for system-wide learning to occur
• because there should be no distinction between investigations for stillbirths and other deaths
• because of concern about asking parents to make a choice at an extremely difficult and distressing time - also bearing in mind that, if parents chose not to give consent at that time, they might later regret it

A bereaved parent said:

Because stillborn babies should be treated the same way as anyone else, and because every baby’s investigation could contribute to system-wide learning and research.

However, others strongly disagreed that no consent should be required. Reasons for this were that:

• mandatory coroner investigations could be distressing and intrusive
• any delays in the coronial process, and having medical records disclosed and questioned in a public hearing could cause additional distress for families
• the requirements and practices that a coronial investigation might entail - for example, post-mortem examination or examination of the placenta - may not align with some parents’ religious or cultural views

A bereaved mother said:

If there was a coroner’s inquest, my baby would have been taken away to be autopsied against my wishes, which would have made me hysterical on a labour ward. I then would have been hauled before the coroner at a public inquest to answer questions. I would have been publicly questioned on my weight, eating habits, general health, lifestyle, sex life etc to see if they caused my child’s death. It would have destroyed me.

Some respondents said that the coroner’s investigation of a stillbirth should include a duty to hold an inquest. However, there were concerns about inquests being a lengthy process that would cause families and maternity staff distress, and could have impacts on parents that may want to try for another baby.

Some respondents thought it would be unnecessary for an inquest to be held for every term and post-term stillbirth, and that some stillbirths could have a preliminary enquiry but not proceed to an investigation (for example, where a stillborn had known conditions that were not compatible with life), or that an inquest should be at the discretion of the coroner.

There were concerns raised about inquests creating a defensive environment and that people called in to give evidence often feel as if they are being challenged.

Further concerns included the impact of inquests on clinical professionals, including the requirement for time away from frontline care, but also negative impacts on staff motivation and wellbeing.

Some respondents supported the proposals for the links and sequencing between coronial and non-coronial investigations - that is that coroners should wait for other investigations to reach a conclusion before opening an investigation.

Some respondents were concerned about potential for overlap (and interaction issues) between coroner investigations and the MNSI programme and trust or health board clinical investigations, which could lead to confusion for families if the coronial investigation and clinical report have different findings. They were also unsure as to what coronial investigation could add to the existing investigation processes.

Other issues raised included:

• drawing on other investigations may compromise the coroner’s ability to provide an independent account
• the impact of possible delays to the commencement or progress of the coronial investigation
• the coronial investigation would not add anything new or beneficial to the existing investigation processes carried out by the MNSI programme or trust or health board investigations

Chapter 4: the powers of the coroner

This chapter looks at the proposed powers that would be exercised by coroners in investigating stillbirths.

Some respondents said that coroners should have the same powers in relation to evidence, documentation and witnesses in stillbirth investigations, as well as in ordering post-mortem examinations, as they do for death investigations, and that coroners should not have to obtain consent or permission from any third party in exercising their powers.

Reasons provided were that stillbirths should be investigated in the same way as deaths and, therefore, coroners should have the same powers in relation to stillbirth investigation.

However, some respondents felt strongly that consent should be sought from parents in order for coroners to exercise their powers in relation to stillbirth investigation, and that not providing a mechanism for parental consent would add to the bereaved family’s distress.

A bereaved family member said:  

You clearly have no idea what it’s like for your baby to be stillborn. [An investigation]’s absolutely not always necessary and it needs to be a choice… you cannot imagine the distress it would have caused us to have to endure a post-mortem and investigation after our daughter’s death.

Respondents raised the following concerns:

• the impact on coronial investigations of the current lack of perinatal pathology resources (due to recruitment issues)
• that midwives and other clinical staff would be diverted from frontline care to participate in inquests, and funding for frontline services may be redirected towards covering legal costs
• that the mother would be ‘blamed’ for the stillbirth because of her behaviour or lifestyle choices during the pregnancy
• that the coroner would have legal control of the baby’s body straight away and, therefore, families would be unable to take the baby home immediately as part of the grieving process

A pathologist said:

This is a medical issue, often… [for] a multidisciplinary team to work out, not for the legal system to address it.

A charity representative said:

We must not have a situation where a woman is in the witness box defending how she managed her health during pregnancy. The proposals do not offer reassurance for how inquests will be managed where mothers with high BMI/who smoke/have complex social issues will be cross-examined about their behaviours contributing to the death of their baby.

Some respondents said that there should be different approaches applied to the investigation of stillbirths, such as the use of less invasive post-mortem procedures.

In response to ‘what, if any, other powers should coroners exercise to aid their investigations into stillbirths?’, respondents suggested that:

• stillbirth investigations should be prioritised over investigations of other deaths as findings from the investigation could affect future pregnancies
• families should be involved in the coronial investigation
• media coverage relating to stillbirth cases should be restricted to protect the anonymity of the bereaved family

Some respondents said that it would be appropriate for coroners to assume legal custody of the placenta. However, some respondents were strongly opposed and suggested that the placenta should only be examined if consent has been provided by parents, and that the placenta should be returned to the family if requested.

Chapter 5: the extent of coronial jurisdiction in cases of stillbirth

This chapter considers which stillbirths should be in scope of the coroner’s jurisdiction.

Some respondents did not support the proposal to investigate only term and post-term stillbirths. There were a wide range of suggestions about which cases should be included and excluded - for example, only including those that were likely to provide substantial learning and excluding those where, for example, a stillborn had known conditions that were not compatible with life, or cases where a family knowingly continued with a pregnancy when they knew the fetus would not survive.

Some of the suggestions for cases that could be included and excluded are outlined below.

Suggestions for inclusion included cases where:

• there is concern about the quality of antenatal care or where the mother had no antenatal care
• there are complications in the pregnancy or there are complex medical issues
• the stillbirth took place at home
• a placenta has been found in circumstances in which it is not clear that a baby has been born alive and appropriately registered - for example, a concealed pregnancy with no witnesses
• there is suspicion of foul play or deliberate harm
• a pregnancy has been alleged to have resulted as a consequence of rape or in the conduct of other illegal activity (for example, human trafficking or illegal drug use)

Suggestions for exclusion included cases where:

• there are known conditions not compatible with life - for example, some chromosomal abnormalities or conditions
• a family knowingly continued with a pregnancy when they knew the fetus would not survive
• there is less likelihood of providing answers

Some respondents suggested expanding the remit for investigation to cases after 24 weeks’ gestation to obtain a wider range of learning and ensure inclusivity for a greater number of families.

Others did not support expanding the remit for 2 reasons:

• many stillbirths are unavoidable and investigating these stillbirths would not provide substantial learning
• it would be impractical to investigate all stillbirths due to the impact upon coronial and pathology resources

Other suggestions were that:

• the coroner could review on a case-by-case basis
• pre-term stillbirths could have a preliminary review with an option to refer to the coroner
• a classification of ‘natural’ and ‘unnatural’ (as is used for other deaths) could be used to determine whether the case should proceed to investigation

However, there was uncertainty about how the classification of ‘natural’ and ‘unnatural’ would apply to stillbirths, and concern that coroners would not have the medical expertise to make this kind of judgement in any event.

It was noted that there would also be an impact upon medical professionals working in maternity and neonatal services who would need to spend time away from frontline care to complete witness statements and give evidence at the inquest.

A midwife said:

All stillbirths, intrapartum, antepartum, from 24 weeks’ gestation onwards.

An obstetrician said:

There should be a distinction between expected and unexpected deaths. We often care for women who carry babies with severely life-limiting problems and often these babies die in utero close to term. These do not require investigation.

An academic said:

Only those where the parent(s) are unhappy with the explanation (or lack of it).

Chapter 6: registration of a stillbirth where the coroner is involved

This chapter considers a proposed process for registering a stillbirth when it is reported to the coroner.

Some respondents supported the proposals set out in this chapter for the 4 different scenarios:

1. Scenario 1 - there is no doubt that the baby was stillborn before 37 weeks’ gestation.
2. Scenario 2 - there is no doubt that the baby was stillborn at or after 37 weeks’ gestation.
3. Scenario 3 - a stillbirth that has been registered with a medical certificate of stillbirth without any prior inquiry by the coroner is finally reported to the coroner.
4. Scenario 4 - it is unclear whether the baby was born before or from 37 weeks’ gestation.

However, some respondents were concerned about potential impacts on bereaved families. They wanted to ensure that there would not be any delays in receiving the final stillbirth certificate (when a baby is stillborn, the registrar will keep the medical certificate of stillbirth and they will issue a certificate of registration of stillbirth), which could cause distress to families.

Respondents wanted to ensure that the process for registration was not lengthier or more complex than at present. There was concern that the stillbirth registration system could end up treating pre-term and term stillbirths differently, and that families who have experienced a term stillbirth may have to go through a more complex registration process.

Chapter 7: impact assessment

This chapter sets out a series of specific questions on the impact of the proposals introduced in chapters 1 to 6. An impact assessment (IA) of the potential impact of those proposals was published alongside the consultation documentation.

Some respondents said that the majority of stillbirth investigations would require a post-mortem examination. They also estimated that, in 20% of cases where there was an inquest, the inquest would be conducted on the basis of written evidence, but 80% would require witnesses to attend and give oral evidence.

There were mixed views about a range of issues including:

• the upper-bound cost of post-mortem examinations, and the cost of a documentary inquest and full inquest hearing
• the time the coroner and the coroner’s officer would need to investigate a stillbirth case
• the capacity of assistant coroners to investigate stillbirths
• assumptions about the impact of coronial investigations on NHS staff time, and the impact on perinatal pathologists’ time to investigate a stillbirth

Two key issues cited were:

• coronial investigations could have a negative impact on NHS staff morale and affect NHS workload
• the current lack of perinatal pathology resources to undertake additional post-mortem examinations relating to stillbirth investigation

Chapter 8: equalities

This chapter considers the impact of the consultation proposals on groups who share a relevant protected characteristic under the Equality Act 2010.

Some respondents suggested that coronial investigations of stillbirths could have an impact on certain religious or cultural groups’ requirements and practices following a stillbirth.

A legal professional said:

… there will be religious and/or cultural issues around this initiative, including post-mortems without consent, which need to be taken into account in terms of how this initiative is brought into practice.

Respondents were concerned that there would be impacts on:

• black, Asian and other minority ethnic women
• women who are socially disadvantaged
• women facing complex, interconnected vulnerabilities who are at higher risk of stillbirth

It was suggested that there should be:

• safeguards in place to avoid language that can add to feelings of blame and guilt
• legal support for parents
• translation and accessibility services
• protection for women from having their medical records made public and choices about their bodies examined in a public court hearing

It was suggested that, if this policy was taken forward, there could be impacts on women whose stillbirths do not fit the criteria for having a coronial investigation which they might wish to have (for example, due to gestational age at which the stillbirth occurred).

A concern was noted that mandatory engagement with the coronial system, especially without adequate support, could increase the risk of fractured, distrustful relationships with public services and substantially increase the trauma of stillbirth for many families.

Annex: analysis of responses

The following tables include the number and nature of responses to the long consultation (LC) and short consultation (SC) questions.

Total number of responses

Table 2: total number of responses to the consultation documents

Consultation	Number of responses
LC	295
SC	39
Total	334

Tables 3 to 10: analysis of consultation responses

Two types of questions were used in the consultation: a closed yes or no question and an open question, which required an open text response.

Where there was a yes or no question, we have included the number and percentage of respondents who answered the question, and the number of those who agreed and disagreed with the question.

Where a yes or no question was accompanied by a supplementary open question, the table below does not indicate the number of respondents who provided a response to the supplementary question.

Table 3: chapter 1 - the need for coronial investigations

Question number	Number and percentage of respondents who answered the question	Number of respondents who answered ‘yes’	Number of respondents who answered ‘no’
LC Q1 (and SC Q1): Do you think coroners should have a role in investigating stillbirths?	322 (96%)	244	78
LC Q2: Do you consider that coronial investigations of stillbirths would achieve the policy objectives set out in paragraph 41?	270 (92%)	200	70

Table 4: chapter 2 - duties of the coroner and investigation outcomes

Question number	Number and percentage of respondents who answered the question	Number of respondents who answered ‘yes’	Number of respondents who answered ‘no’
SC Q2: Do you agree with our proposals for the determinations and recommendations to be made by coroners?	36 (92%)	34	2
LC Q3: Do you agree with the proposal about ascertaining who the mother of the stillborn baby is and the baby’s name if they have been given one? Do you think there is anything else that should be considered?	265 (90%)	235	30
LC Q4: Do you agree with the proposal about ascertaining how it was that the baby was not born alive? Do you think there is anything else that should be considered?	263 (89%)	228	35
LC Q5: Do you agree with the proposal about ascertaining when fetal death occurred or was likely to have occurred, and when the baby was delivered stillborn? Do you think there is anything else that should be considered?	270 (92%)	226	44
LC Q6: Do you agree with the proposal about ascertaining where fetal death occurred or was likely to have occurred, and where the stillborn baby was delivered? Do you think there is anything else that should be considered?	265 (90%)	208	57
LC Q7: Do you agree that, as part of their findings, coroners should identify learning points and issue recommendations to the persons and bodies they consider relevant? If not, how do you think coroners should disseminate learning points?	274 (93%)	235	39
LC Q8: Beyond identifying learning points in individual cases, do you think coroners should have a role in promoting best practice in antenatal care?	245 (83%)	Open question	Open question
LC Q9: Is there anything else you would like to see come out of a coroner’s investigation into a stillbirth? What other determinations should be made?	185 (63%)	Open question	Open question

Table 5: chapter 3 - procedures and links with non-coronial investigations

Question number	Number and percentage of respondents who answered the question	Number of respondents who answered ‘yes’	Number of respondents who answered ‘no’
LC Q10 (and SC Q3): Do you agree that no consent or permission from the bereaved parents, or anyone else, should be required for a coronial investigation into a stillbirth to be opened?	299 (90%)	191	108
LC Q11 (and SC Q4): Do you agree that the coroner’s duty to hold an inquest should apply to investigations of stillbirths?	288 (86%)	206	82
LC Q12: Do you agree with the proposals for the links and sequencing between coronial and non-coronial investigations?	236 (80%)	177	59

Table 6: chapter 4 - the powers of the coroner

Question number	Number and percentage of respondents who answered the question	Number of respondents who answered ‘yes’	Number of respondents who answered ‘no’
LC Q13: Do you think coroners should have the same powers in relation to evidence, documentation and witnesses in stillbirth investigations, as well as in ordering medical examinations, as they do for death investigations now?	257 (87%)	198	59
LC Q14: What, if any, other powers should coroners exercise to aid in their investigations into stillbirths?	140 (47%)	Open question	Open question
LC Q15: Do you think it is appropriate for coroners to assume legal custody of the placenta? If not, why?	249 (84%)	182	67
LC Q16: Do you agree that coroners should not have to obtain consent or permission from any third party in exercising their powers, except where existing rules already provide for such a requirement? Please give your reasons.	249 (84%)	188	61
SC Q5: Do you agree with our proposals for the powers that coroners should have in investigating stillbirths, and that they should not have to obtain consent or permission in exercising these powers? Please give your reasons.	36 (92%)	25	11

Table 7: chapter 5 - the extent of coronial jurisdiction in cases of stillbirths

Question number	Number and percentage of respondents who answered the question	Number of respondents who answered ‘yes’	Number of respondents who answered ‘no’
LC Q17: Do you agree with the proposal to investigate only term and full-term stillbirths, or do you think the obligation to investigate should encompass all stillbirths?	238 (81%)	70	168
LC Q18: If you answered ‘no’ to both parts of the question above, which group of stillbirths do you think should be investigated?	139 (47%)	Open question	Open question
LC Q19: Do you agree that coroners should investigate all term and full-term stillbirths (in other words, all stillbirths in scope)? Or do you think a further distinction should be made within this category?	236 (80%)	152	84
SC Q6: Do you agree with the proposal that coroners should investigate all term and full-term and post-term stillbirths, and no other stillbirths? If not, which stillbirths do you think coroners should investigate and why?	36 (92%)	19	17

Table 8: chapter 6 - registration of a stillbirth where the coroner is involved

Question number	Number and percentage of respondents who answered the question	Number of respondents who answered ‘yes’	Number of respondents who answered ‘no’
LC Q20: Do you agree with the above proposal as to how a stillbirth should be registered when a coronial investigation has taken place?	234 (79%)	167	67

Table 9: chapter 7 - impact assessment

Question number	Number and percentage of respondents who answered the question	Number of respondents who answered ‘yes’	Number of respondents who answered ‘no’
LC Q21.1: Do you agree with the assumption that the majority of stillbirth investigations would require a post-mortem examination (in the IA we have used an upper bound estimate of 100%)?	215 (73%)	170	45
LC Q21.2: We have also assumed that an upper bound estimate of the cost of a post-mortem examination for a stillbirth is £2,000. We recognise that this varies by region and so would appreciate views on this, and particularly any evidence on the average cost of a stillbirth post-mortem examination in your region.	96 (33%)	Open question	Open question
LC Q22: Do you agree with the assumption that the inquest in approximately 20% of stillbirth investigations could be conducted solely on the basis of written evidence (this is sometimes referred to as a documentary inquest) and approximately 80% would require witnesses to attend and give oral evidence?	170 (58%)	113	57
LC Q23: Do you agree with our assumption that a stillbirth case is complex in nature and would require around 4 hours of coroner’s time and around 15 hours of coroner’s officer time to review the case (excluding time spent at the inquest)?	169 (57%)	124	45
LC Q24: Do you agree with our assumptions that: – (i) the investigation of stillbirth cases is likely to be undertaken by a senior or area coroner and would be resourced by increasing the number of assistant coroners to deal with the less complex cases currently undertaken by senior or area coroners; and – (ii) assistant coroners would take the same number of hours on these cases that have been redistributed as senior or area coroners?	157 (53%)	123	34
LC Q25: We would welcome views on the assumption in the IA that the average cost of a documentary inquest is £400 and the average cost of a full inquest is £3,000 (including coroner costs, investigating officer costs, witness costs and court building costs).	87 (29%)	Open question	Open question
LC Q26: Do you agree with our assumption that a coronial investigation of a stillbirth could require up to 6 members of NHS staff (medical consultant, junior doctor, 3 midwives/nurses and an NHS manager) to each provide up to a maximum of 7 hours of their time?	170 (58%)	114	56
LC Q27.1: Do you agree with our assumption that one full-time equivalent (FTE) perinatal pathologist is capable of undertaking between 100 and 200 stillbirth post-mortem examinations a year whereby if coronial investigations of stillbirths result in an additional 450 post-mortem examinations per year, this implies between 2.25 and 4.5 additional FTE perinatal pathologists would be required to meet the anticipated additional workload?	139 (47%)	103	36
LC Q27.2: What percentage of the additional stillbirth post-mortem examinations that may be requested in your region would there be a capacity and willingness to complete?	93 (32%)	Open question	Open question
LC Q27.3: If your answer to question 27.2 is not 100%, what alternative funding arrangements do you think would be required to support the increased demand for post-mortem examinations of term/full-term stillbirths?	72 (24%)	Open question	Open question
LC Q28: What impact do you think coronial investigations of stillbirths will have on investigations of stillbirths undertaken: – a) locally; and – b) by the HSIB? Will the current investigation of stillbirths continue independently of coronial investigations or will some current activity be displaced or otherwise impacted by coronial investigation of stillbirths?	122 (41%)	Open question	Open question

Table 10: chapter 8 - equalities

Question number	Number and percentage of respondents who answered the question	Number of respondents who answered ‘yes’	Number of respondents who answered ‘no’
LC Q29: Do you think the proposals in chapters 1 to 6 may have any further impact on a group with a protected characteristic?	168 (57%)	77	91
SC Q7: Do you think the proposals could have any further impact on a group with a protected characteristic?	28 (72%)	6	22