Coronial Investigations of Term Stillbirths: Summary of Responses to the Consultation

I wish to update the House on the responses received to a joint consultation by the Department of Health and Social Care and Ministry of Justice on coronial investigations of stillbirths in England and Wales.

Over the years, there have been calls from bereaved families, charities and others for a more transparent and independent process for determining the causes of, and learning from, stillbirths. Some of those calling for change identified coronial investigations as the way to deliver an improved process.

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.

The consultation sought views on proposals on whether, and if so how, coronial investigations of stillbirth cases could take place in England and Wales.

The objectives of the proposals, which were co-developed with stakeholders, were to:

bring greater independence to the way stillbirths are investigated;

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

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

Some 334 people responded to the consultation and 63 people attended our stakeholder workshops. I and my ministerial colleague at the Ministry of Justice are extremely grateful to those who responded and shared their views, particularly families who have experienced stillbirth and shared their personal and often tragic experiences. This was so important to us in considering our response.

Work to respond to the consultation was paused during the pandemic. Today I am sharing a factual summary of the consultation findings. The findings of the consultation were complex: there were mixed views about proposals that coroners should have a role in stillbirth investigations and where they were supportive, about the way in which coronial investigations would be carried out.

In addition, the landscape of maternity investigations has changed significantly since the consultation. The maternity and new-born safety investigations programme is now in place, which aims to provide independent, standardised and family focused investigations for families; to provide learning to the health system via reports at local, regional and national level; analyse data to identify key trends and provide system wide learning; be a system expert in standards for maternity investigations; and collaborate with system partners to escalate safety concerns. Additionally, the perinatal mortality review tool supports standardised perinatal mortality reviews across NHS maternity and neonatal units in the UK. Going forward, my officials are working to improve the information available to families regarding these investigative processes that may be taken forward following a stillbirth. I wish to reassure the House that a further statement will be issued in due course, which sets out whether, and if so, how the Government intend to take action.