New powers to investigate stillbirths

26 Mar 2019 01:57 PM

Bereaved parents who suffer a stillbirth would gain answers from an independent inquest into their baby’s death under plans to improve the way such tragedies are investigated.

• Government acts to help bereaved parents find answers following stillbirth
• New plans for coroners to investigate stillbirths
• Part of wider plans to help prevent future stillbirths and improve maternal care

The government today (26 March 2019) launched a consultation on proposals to give coroners the power to investigate all full-term stillbirths – which would help provide parents with vital information on what went wrong and why, while ensuring any mistakes are identified to prevent future deaths.

Respond to the consultation: Coronial investigations of stillbirths

At present, coroners can only hold inquests for babies who have shown signs of life after being born. They cannot investigate where the pregnancy appeared healthy but the baby was stillborn. In these circumstances the Healthcare Safety Investigation Branch must investigate the death.

While many parents are satisfied with existing processes, some have raised concerns about the inconsistency of investigations and have called for a more transparent and independent system.

Ministers are therefore asking for views on whether coroners should be able to investigate stillbirths. As judicial office holders, coroners would not only be able to provide parents with much needed answers but also make recommendations to prevent future avoidable deaths.

In addition, the proposed system will ensure that both bereaved parents and medical staff are involved at all stages of the process.

Justice Minister Edward Argar said:

A stillbirth is a tragedy which has a profound effect upon bereaved families. We must ensure that every case is thoroughly and independently investigated.

These proposals would ensure that bereaved parents have their voices heard in the investigation, and allow lessons to be learnt which would help to prevent future stillbirths.

Health Minister Jackie Doyle-Price said:

We want to do everything we can to make pregnancy safer, by continually learning to improve the care on offer so fewer people to have to experience the terrible tragedy of losing a child and those who do get the answers and support they deserve.

Rates of stillbirths in England are the lowest on record, but we’re committed to delivering on our ambition in the NHS Long Term Plan to accelerate action to halve this number by 2025.

This is a complex issue and it’s important we get it right by listening carefully to those who are affected by these issues, so I urge everybody to have their say on this consultation. By sharing your experiences you can ensure any decision we make puts women, loved ones and their babies first.

Kate Mulley, Director of Research, Education and Policy at Sands said:

At Sands bereaved parents often tell us how vitally important it is to understand why their baby died and that the best legacy for their baby is to ensure that lessons are learned to prevent future deaths.

We believe their views must be taken into account when determining any changes in the role of coroners. This consultation by the Ministry of Justice raises important questions and we would encourage anyone affected to make their views known.”

The joint consultation from the Ministry of Justice and the Department for Health and Social Care seeks a wide range of views, from bereaved parents, the organisations that support them or that provide advice to pregnant women, researchers, health professionals and healthcare providers, as well as those working for coronial services.

Under the proposed system:

• Coroners will have powers to investigate all full-term stillbirths occurring from 37 weeks pregnancy
• The coroner will consider whether any lessons can be learned which could prevent future stillbirths
• Coroners will not have to gain consent or permission from any third party in exercising this power
• Coronial investigations will not replace current investigations undertaken by the hospital or NHS agencies

Whilst the UK’s rates of stillbirth are the lowest on record and we have seen year-on-year falls in the proportions of pregnancies that end in a stillbirth, the government is clear that more must be done.

These measures are an important step towards delivering the government’s commitment to reduce the rate of stillbirths and make the NHS the safest place in the world to give birth.

Notes to editors:

• Coroners’ duties are supported by a number of powers and safeguards set out in statute, which support an unbiased and transparent process.
• This builds on the government’s relaunched Maternity Safety Strategy (November 2017) to support the government’s ambition to halve the rate of stillbirths by 2025. The then Health Secretary, Jeremy Hunt MP committed to consider whether and how coroners could carry out investigations into babies who are stillborn at term.
• The Civil Partnerships, Marriages and Deaths (Registration etc) Bill requires the Secretary of State to submit a report to Parliament on whether it will and if so how, the law ought to be changed to enable or require coroners to investigate still-births.
• Coronial investigations would not replace the role others have in reviewing stillbirths such as those undertaken by local NHS services using the Perinatal Mortality Review Tool and those provided by the Health Service Investigation Branch (HSIB). Currently all term stillbirths where the baby dies during labour or birth are investigated by the HSIB.
• As with current coronial inquests such reviews may form part of the coroner’s investigation into a stillbirth.
• Coronial stillbirth investigations would reflect the rules and principles that currently underpin the coronial process, including those relating to the conduct of an inquest and the coroner’s powers to access evidence and manage the disclosure of documents, to order relevant medical examinations of the stillborn baby and the placenta, to retain legal custody over the stillborn baby and the placenta until they are no longer required for the purposes of the investigation, and to compel witnesses to give evidence.
• Under current law, the role of the coroner is to determine how, when and where someone died if the death was violent or unnatural, if its cause is unknown, or where the deceased died whilst in custody or under state detention. The coroner’s duty is in relation to adults, children and babies who were born alive, but not stillbirths.
• If there is any doubt whether a baby was born alive, a coroner can undertake enquiries as to whether there is a duty to investigate, but they will not investigate further if they conclude that it was a stillbirth.
• The consultation will run for 12 weeks, closing on 18 June 2019.
• The proposals would apply in England and Wales.