Campaigners are calling for a more rigorous system for baby deaths to be examined and lessons to be learned – but action is yet to be taken, reports Katie Tarrant

The Government has not responded to a consultation on inquests into stillbirths, almost two years after it was delivered – despite campaigners saying that the holding of independent coroners’ inquiries into baby deaths could help tackle the UK’s high stillbirth rate.

MPs recently reported that 1,000 babies die preventable deaths every year in England because maternity wards can be prone to shifting blame and trusts do not always learn from their mistakes. Hospitals are obliged to conduct internal investigations into all baby deaths, including stillbirths, but they are not subject to an independent inquest by a coroner.

The damning report by the Health Select Committee revealed that almost two in five childbirth units “require improvement for safety”, although it did praise the “impressive” 30% fall in neonatal deaths and 25% drop in stillbirths over the past decade.

But Professor Ted Baker, the Care Quality Commission’s chief inspector of hospitals, told the committee that a “defensive culture” persists within maternity units, whereby “dysfunctional teams and poor quality investigations” are present.

Despite the drop in stillbirths, 1,200 babies every year are stillborn. One-third die after a full-term pregnancy (37 or more weeks), when a baby has the greatest chance of surviving. The UK still has one of the worst rates compared to other rich Western countries. 

A joint consultation by the Ministry of Justice and the Department of Health and Social Care (DHSC) in March 2019 proposed that coroners should be given the power to investigate all full-term stillbirths occurring from 37 weeks of pregnancy. This would not cover the full definition of a stillbirth – a baby born without signs of life after 24 weeks of pregnancy – but it signalled a step in the right direction for some campaigners. 

The Government’s response to the consultation, promised in September 2019, is yet to be published. The DHSC told Byline Times that “work on analysing the responses to the consultation on coronial investigations of stillbirths has been delayed during the COVID-19 pandemic”, but that it hopes to respond as soon as possible.

Ryan Jackson, who founded the Lily Mae Foundation with his partner Amy after their daughter was stillborn in 2010, believes that the proposals made in the consultation should be enshrined in law, and that the coroner’s ability to “adduce sufficient evidence” and “draw on a wide range of independent expertise should be a process in which the bereaved family should be an active participant”.

He said that extending the scope of coronial investigations to encompass stillbirths would be vital for achieving former Health Secretary Jeremy Hunt’s commitment to reducing stillbirths, neonatal and maternal deaths in England by 50% by 2030. 

Leading stillbirth and neonatal death charity Sands said that a “sea change” would be required to reach this target at the Government’s current rate of progress. 

Maternity wards have been encouraged to use the Government-funded Perinatal Mortality Review Tool (PMRT) since 2018, which collates data from internal investigations and shares it across NHS trusts for greater learning. The Government has also further invested in the Healthcare Safety Investigative Branch (HSIB), which undertakes approximately 1,000 external independent investigations every year. After deaths are reported to it, the HSIB liaises with grieving parents to produce a report with recommendations. However, the onus is on the hospital to implement ideas for improvement. 

The concept for the PMRT was established by Sands. Its director of research, education and policy, Kate Mulley, said it promoted learning opportunities across the NHS, but warned that it “is only as good as the way that the unit is using it”. 

“In the really good units, they will sit down with a multidisciplinary team that’s resourced to take the time to meet and they will talk openly and honestly with the parents’ input,” she told Byline Times. “Every parent must be properly included within the process.” 

But MPs, charities and campaigners warn that a “blame” culture can hamper these investigations.

Learning Lessons and Saving Lives

For as many as four in 10 stillborn babies, the cause of death is not known. When hospital reviews cannot establish the cause of the stillbirth, grieving parents are left without answers and the health of the mother and any of her future children is put at risk. 

Baishali Clayton, a medical negligence solicitor with Nelsons, said that she is often approached by clients who are dissatisfied with internal processes. “We frequently encounter families who feel they have been wronged by the hospital’s investigation process, and I am sure I have yet to see an investigation report that was satisfactory and addressed all the issues,” she told Byline Times.

“In one case, my client was never given an explanation as to why she had suffered her stillbirth and her questions were repeatedly dismissed until she was several months pregnant with her next baby. Only then was she told that her placenta had failed the first time around and that she should not be allowed to proceed to a full-term natural delivery, and that she would need a caesarean section this time.”

Clayton highlighted that widening the scope of coroners’ inquests to cover all stillbirths could save lives. “I deal with many maternity negligence cases and I find it heartbreaking that legal distinctions are drawn between a baby pre- and post-24 weeks’ gestation, and again if they are born breathing or not,” she said. “A baby is a baby, from the second their heart starts beating they are an entity to someone.” 

Proposals for coroners’ investigations would not replace current investigations undertaken by hospitals or NHS agencies, but their impact could be much greater. 


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If a coroner finds that lessons could be learned from any particular case, they are required to produce a Prevention of Future Deaths report (PFD), which imposes a duty on the hospital trust or other relevant organisation to respond to the PFD, confirming any learning points and changes that have been implemented. 

A hospital trust took four years and a negligence claim to concede that it was inappropriate to deliver a stillborn baby five days after she had died for another of Clayton’s clients. “During the initial trust investigation, our client was told that it was too busy on the maternity unit to deliver her any sooner,” she said.

The client proved that her baby had died as a result of negligent care, but the claim was not settled until five years after the stillbirth. “This demonstrates the clear benefit of an inquest,” Clayton added. “It would not have taken five years of fighting for the parents to get answers for why their baby died had a coroner’s court investigated this case.”

Sands reports that, in rare cases, coroners will investigate full-term stillbirths where there is strong evidence of negligence, but there is currently no such legal duty on them to do so.

“Existing review processes should involve parents and answer their questions but when those questions are not answered, we believe the coroner may play a vital role in providing answers, ensuring that lessons are learned and mistakes are not repeated,” said Kate Mulley. 

However, she warned that coronial inquests may always not be the answer: “Inquest process will not be appropriate in many cases of stillbirth. We need to ensure that coronial processes, which can be extremely prolonged and painful for families, do not cause additional emotional harm to bereaved parents.”

A spokesperson for the Department of Health and Social Care said: “This Government is dedicated to reducing stillbirths and other adverse maternity outcomes and making sure that grieving families have access to the support they need. Maternity safety is a priority and we are on track to surpass our ambition for a 20% reduction in the stillbirth rate and the neonatal mortality rate.

“We know there is more to do be done, and the Government is backing NHS maternity leaders with investment to help improve workplace culture, while also funding a plan to reduce birth-related brain injuries and better match maternity staffing to local needs.”


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