House of Commons Library

The investigation of stillbirth

Published Thursday, February 1, 2018

This Commons Library briefing paper deals with the way stillbirth is investigated at present, the Government announcement about independent investigations, and the role of coroners

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This briefing paper deals with the position in England and Wales.

Current investigation of stillbirth in England and Wales

All unexpected or avoidable deaths, including those of mothers or babies, which may have been the result of healthcare failings should currently be investigated as serious incidents, under NHS England and NHS Wales national frameworks.

The Department of Health and the Welsh and Scottish Governments have also jointly commissioned a standard Perinatal Mortality Review Tool, to assist maternity and neonatal units in investigating all stillbirths and perinatal deaths. A pilot was launched in summer 2017, with full rollout planned for the end of the year.

Coroners and stillbirth

At present coroners do not have power to investigate a stillbirth. There has to have been an independent life before the coroner has jurisdiction to investigate a subsequent death.  The definition of stillbirth is based on there not having been an independent life, meaning that the coroner does not have jurisdiction to investigate. 

There have been a number of calls for the law to be changed, including by Sands, the stillbirth and neonatal death charity, and in Parliamentary debate.

In Northern Ireland, which has its own legislation, the position is now different. In 2013, in a landmark decision, the Northern Ireland Court of Appeal held that coroners do have jurisdiction to carry out an inquest on a child that had been capable of being born alive.

Government announcement about independent investigations in future

On 28 November 2017, Health Secretary, Jeremy Hunt, made a statement to the House on the Government’s new strategy to improve safety in NHS maternity services. As part of this strategy, from April 2018, the Healthcare Safety Investigation Branch (HSIB) will investigate every case of a stillbirth, neonatal death, suspected brain injury or maternal death notified to the Royal College of Obstetricians and Gynaecologists (RCOG) Every Baby Counts programme, amounting to around 1,000 incidents per year.

Jeremy Hunt also said that he would work with the Ministry of Justice “to look closely into enabling, for the first time, full-term stillbirths to be covered by coronial law, giving due consideration to the impact on the devolved Administration in Wales”.

Civil Partnerships, Marriages and Deaths (Registration Etc.) Bill 2017-19

In July 2017, having come fifth in the Private Members’ Bill ballot which took place in June 2017, Tim Loughton (Conservative) introduced the Civil Partnerships, Marriages and Deaths (Registration Etc.) Bill 2017-19 (the Bill).  Explanatory Notes have been prepared by the Home Office with the consent of Tim Loughton.  The Bill is due to have its second reading on 2 February 2018.

The Bill would require the Secretary of State to “make arrangements for the preparation of a report on whether, and if so how, the law ought to be changed to enable or require coroners to investigate still‑births”. The Secretary of State would be required to publish the report. Following publication, the Lord Chancellor would have power to make “investigation regulations” which could amend Part 1 of the Coroners and Justice Act 2009.

The Bill would also deal with a number of other matters. Another Library briefing paper provides further information: Commons Library analysis: Civil Partnerships, Marriages and Deaths (Registration Etc.) Bill

Commons Briefing papers CBP-8167

Authors: Catherine Fairbairn; Alex Bate; Oliver Hawkins

Topics: Coroners, Death, Health services, Registration of births, deaths and marriages

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