Coronial Investigations for Stillbirths

The government is seeking views from bereaved parents and their families on proposals for introducing coronial investigations of stillbirth cases in England and Wales.

Currently, the organisations where the death took place carry out their own investigations and coroners can only become involved if a baby has shown signs of life once born. The new plans would allow coroner involvement for stillbirths from 37 weeks onwards.

“Coroners are independent judicial officers who investigate deaths reported to them. They will make whatever inquiries are necessary to find out the cause of death, this includes ordering a post-mortem examination, obtaining witness statements and medical records, or holding an inquest.” – Quoted from nidirect Government Services.

There has long been concerns about organisations carrying out their own investigations following a stillbirth and many families have suffered long and difficult journeys in discovering what went wrong.
The Perinatal Mortality Review Tool (PMRT) has improved and standardised the quality of reviews and strongly encourages parental involvement which is absolutely key to finding out what has happened. We heard at a conference a while ago of some trusts working together with neighbouring trusts to independently review each case to ensure a “fresh eyes” approach which again is a great step forward. Not all trusts have this in place and it was clear that resources and the coordination of this best practice approach really is not as simple as it may initially sound to those outside the NHS. Although the PMRT does standardise and vastly improve the quality of the review process, this illustrates just one example of how trusts may still use the tool differently in different areas.

You may have also heard of HSIB. The Healthcare Safety Investigation Branch was tasked in November 2017 to undertake around 1000 independent safety investigations for cases of stillbirth, early neonatal deaths and certain cases of severe brain injury. Their investigations are primarily focussed on learning and not attributing blame with the involvement of the family a key priority. They say:
“Sharing learning from these local investigations is crucial and as an independent national body we will build a bigger picture of the issues and generate wider recommendations for the system.“
Ultimately HSIB’s findings will provide meaningful safety recommendations for the future.

This article explains how Michelle and Nicky started the Campaign for Safer Births back in 2013 and have been lobbying long and hard for the introduction of coronial investigations for stillbirths.
“In Michelle’s case, it took four years of ongoing litigation before their hospital trust finally admitted negligence leading to the death of Michelle’s son Louie.”

Heidi, CEO of MAMA Academy says  “This would be such a huge step towards positive change as it would ensure that every death after 37 weeks would get an independent review.”

So what is your experience of the current review process? Is it enough? We urge you to let your views be heard. The foundations have been laid with a tremendous amount of work from the Campaign for Safer Births. Now together we can make our voices heard to help continue to make a difference.

Voice your views here.