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Stillbirths: Coronial Investigations

Volume 657: debated on Tuesday 26 March 2019

I am pleased to announce the publication of a consultation on introducing the coronial investigation of stillbirths in England and Wales (CP 16), which has been laid before the House today.

Under current legislation coroners cannot investigate a death when it is known that the baby was not born alive. If there is doubt whether a baby was born alive, a coroner can investigate—which could include holding an inquest—but must halt that investigation if they determine that the baby was stillborn. Our consultation considers the case for coroners investigating stillbirths and sets out proposals for how these investigations could be undertaken. The proposals seek to deliver three objectives:

to bring greater independence to the way stillbirths are investigated;

to ensure transparency and enhance the involvement of bereaved parents in stillbirth investigation processes, including in the development of recommendations aimed at improving maternity care;

and to effectively disseminate learning from investigations across the health system to help prevent future avoidable stillbirths.

The consultation delivers the Government commitment to consider enabling coroners to investigate stillbirths, made in November 2017, when the then Secretary of State for Health launched a suite of maternity safety strategy initiatives and committed to halve stillbirth rates by 2025.

It is thus a joint undertaking between the Ministry of Justice and the Department of Health and Social Care. I and the Under-Secretary of State for Health and Social Care (Jackie Doyle-Price) are grateful to the many people and organisations that have worked with officials in both Departments as we have developed our proposals.

Since the November 2017 announcement, meetings have been held with a wide range of interested parties including bereaved parents and supporting charities, the chief coroner and a number of senior coroners, NHS representatives, healthcare safety investigation branch officials, officials in the Welsh Government, academics and the Royal Colleges of Pathologists, Midwives, and Obstetricians and Gynaecologists. Their insight and expertise have been invaluable in helping us develop our thinking.

The consultation seeks views on the merits of coroners inquiring into the causes of stillbirths and contains proposals as to when and how those investigations should take place, reflecting existing processes and arrangements for coronial investigations into child and adult deaths.

We propose that all stillbirths that occur at or after the 37 week of gestation should be in scope of an inquest and our proposals cover such matters as access to documents and medical examination of the stillborn baby.

A coronial investigation would provide greater transparency in stillbirth cases. Under our proposals evidence would be available to all interested persons, including the bereaved parents, who may not otherwise have the opportunity to hear or read everything that is presented when a stillbirth is reviewed. The coroner would bring judicial independence which would help build confidence in the conclusions of the investigation.

We propose that coroners should identify where lessons can be learnt from individual stillbirths in ways that will deliver system-wide improvements to the delivery of maternity services and the general care and safety of expectant mothers.

Whilst we have been developing our proposals, the private Members’ Bill promoted by the hon. Member for East Worthing and Shoreham (Tim Loughton), the Civil Partnerships, Marriages and Deaths (Registration Etc.) Bill, has been progressing through Parliament. The Bill, which is supported by the Government, seeks among other things to place a duty on the Secretary of State to prepare and publish a report on whether, and if so how, the law ought to be changed to enable or require coroners to investigate stillbirths. The consultation document takes account of the views expressed by members of both Houses during the debates on the Bill.

The consultation document and an impact assessment have been placed in the Library of the House and are available online at: Copies of the consultation document and the impact assessment are being sent to the stakeholders listed at annex A of the consultation document.

We look forward to hearing from anyone with experience of, or an interest in, this important and sensitive area.

The consultation closes on 18 June and the Government will publish their response later this year.