Inquest or no inquest?
If a baby dies before 24 weeks of pregnancy, this is classed as a miscarriage. A baby born without signs of life after 24 weeks of pregnancy is described as a stillbirth. If a baby dies after they have been born alive, even for a matter of minutes, this is known as neonatal death. All of the above events are hugely devastating and anyone suffering the loss of a baby just wants to know why.
At the current time, a Coroner can investigate the deaths of babies who were born with signs of life. Stillbirths, however, are an area of huge controversy and contention, because inquests are not available where the baby was not born alive.
There is some debate as to whether or not the definition of stillbirth should be applied to any that happen after 20 weeks rather than 24, but the specifics of this do not change the overarching point that in the above scenarios, inquests will only be held in cases of neonatal death and there is currently no scope for a Coroner’s investigation into stillbirths.
Government consultation on coronial investigations of stillbirths
In March 2019, the Government issued a consultation on coronial investigations of stillbirths but this has yet to be progressed. The purpose of the overall process of investigating stillbirths is because many, if not most, stillbirths fall into the category of unknown cause, which is of course incredibly distressing to families and not helpful for clinical learning and how to prevent such deaths in the future.
Moreover, the death of a baby is still the death of a baby to its family and there should be no distinction drawn between stillbirth and neonatal death. Both are equally traumatic and life-changing experiences, requiring scrutiny as to the cause.
Under the proposed Government system:
- Coroners will have the power to investigate all full-term stillbirths occurring from 37 weeks of 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.
There are a number of bodies and initiatives that are working tirelessly to reduce the risk and incidence of stillbirth, but many of them are driven by other significant concerns, such as the prevention of maternal death in pregnancy and childbirth. Absolutely, therefore, there is room for the scope and power of a Coroner’s inquest into stillbirths.
Why involve a Coroner with a stillbirth?
If a Coroner finds that lessons could or should be learned from any particular case, then a Prevention of Future Deaths report (PFD) must be made. There would be a duty by the hospital Trust or other relevant organisations to respond to the PFD, confirming any learning points and changes that have been implemented. At the moment there is no such duty on clinicians in stillbirth cases. The Coronial investigation, with or without a PFD, would promote enhanced patient safety and promote best practices in antenatal care.
The Chief Coroner issued revised guidance on 4th November 2020 on the issuing of new PFDs under the Act. The notable changes are that:
- There is an increased emphasis on the point that PFDs are not intended as a punishment, they are made for the benefit of the public and intended to improve public health, welfare and safety.
- The Coroner should focus on the current position and take into consideration any changes that have already been implemented by the provider to address the areas of concern relating to the issue of future fatalities.
- The Coroner will consider the organisation’s commitment to taking remedial action by way of providing supporting documentation and hearing witness evidence on any such steps taken.
- The Coroner can now also consider other PFDs made to the same organisation in the locality.
Of course, not all stillbirths would need to be investigated by a Coroner. The inquest process is complex and lengthy and can cause additional distress to families at an already traumatic time. Some causes of death will have been adequately addressed by the hospital’s own internal investigation reports. We feel that Coroners should be allowed to consider whether or not to hold inquests into stillbirths on a case by case basis, in direct consultation with the family, where questions remain about the quality of care received.
Was your baby stillborn? What can you do?
Whilst a Coroner may not be able to hold an inquest into your baby’s death, it is likely that the hospital Trust, or a Government organisation, such as the Healthcare Safety Investigation Branch, will have conducted their own investigations into what happened. Sometimes these reports will be helpful to you, but occasionally they may leave you with even more questions.
This is where we can help you. We will take the time to listen to your story, review any investigation reports free of charge and advise you if we think you should consider pursuing a claim for clinical negligence if we have concerns about how your baby died. We work with independent medical experts to investigate what happened, and whether or not the outcome could or should have been different for you and your baby. We will get you answers, and if appropriate, compensation for your loss. We will also help you to seek an apology and request changes to policy and processes to ensure that no other family has to suffer the tragic loss of a baby in the same circumstances.