House of Commons Library

The investigation of stillbirth

Published Wednesday, October 24, 2018

This Commons Library briefing paper deals with the way stillbirth is investigated at present and proposals for change

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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.

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, the then Health Secretary, Jeremy Hunt, made a statement to the House on the Government’s new strategy to improve safety in NHS maternity services. This included an announcement that from April 2018, the Healthcare Safety Investigation Branch (HSIB) would 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. Investigations began in the South region of England in April 2018, with full national roll‑out expected by March 2019.

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 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 was published on 31 January 2018 as Bill 11 of 2017-19, had its Second Reading on 2 February 2018, and Public Bill Committee stage (in one sitting) on 18 July 2018. The Bill as amended in Public Bill Committee has been published as Bill 254 of 2017-19.

Report stage in the Commons is scheduled for 26 October 2018.

Among other things, 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 stillbirths”. The Secretary of State would be required to publish the report. Following publication of the report, the Lord Chancellor would have power to make 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 (CPB 08217).

Commons Briefing papers CBP-8167

Authors: Catherine Fairbairn; Alex Bate; Cassie Barton

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

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