The investigation of stillbirth

This briefing deals with the position in England and Wales except where stated otherwise.

The investigation of stillbirths in the UK

The Department of Health and Social Care and the Welsh and Scottish Governments have jointly commissioned a standard Perinatal Mortality Review Tool (PMRT), to assist hospitals in investigating all baby deaths, from 22 weeks’ gestation onwards, including late miscarriages, stillbirths and neonatal deaths.

All stillbirths should be reviewed by the hospital providing maternity care. The review should be carried out by a multi-disciplinary team to understand the events that led up to the death of the baby. It aims to find out why the death of a baby has occurred, to provide bereaved parents with as much information as possible, and to allow the hospital to learn lessons and improve future care.

The hospital review is different from a coroner's investigation or inquest. For about 90% of parents the PMRT review process is likely to be the only hospital review of their baby’s death that will take place.

In England, all cases of intrapartum stillbirth, where the baby was thought to be alive at the start of labour and was born with no signs of life, are investigated by the Maternity and Newborn Safety Investigations (MNSI) programme.

For information on measures to reduce stillbirth, and to improve the quality of care for bereaved parents, please refer to the Library briefing Quality and safety of maternity care (England).

Coroners and stillbirth

At present, coroners do not have power to investigate stillbirths. 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.

Where there is doubt about whether a child was born alive or stillborn, the coroner can make preliminary enquiries to try to establish the position or can start an investigation.

In Northern Ireland, which has its own legislation relating to coroners, the position is different. In 2013, in a landmark decision (PDF), the Northern Ireland Court of Appeal ruled that coroners do have jurisdiction to carry out an inquest into a stillborn baby that had been capable of being born alive.

Civil Partnerships, Marriages and Deaths (Registration etc) Act 2019

Section 4 of the Civil Partnerships, Marriages and Deaths (Registration etc) Act 2019 requires 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 must publish the report and then the Lord Chancellor may make regulations to amend Part 1 of the Coroners and Justice Act 2009 for specified purposes.

Government consultation 2019

In March 2019, the Government launched a consultation on coronial investigations of stillbirths in England and Wales. This was prepared jointly by the Ministry of Justice and the Department of Health and Social Care.

One of the matters on which the Government sought views was a proposal that stillbirths occurring at or after the 37th week of pregnancy should be in scope of an inquest. The Government said its proposals aimed 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
• effectively disseminate learning from investigations across the health system to help prevent future avoidable stillbirths.

The Government confirmed it was not seeking to replace the role of the NHS in investigating stillbirths (PDF). Instead, coronial investigations would supplement and support those investigations and ensure that coroners could contribute to learning and play a role in reducing the stillbirth rate.

The consultation closed on 18 June 2019. As of 12 October 2023 the Government is still analysing feedback.

In May 2021, the House of Commons Justice Committee recommended that the Ministry of Justice should revive the consultation and publish proposals for reform. The Government’s response, published in September 2021, said the delay in responding to the 2019 consultation was due to the impact of Covid‑19 on work programmes. However, the Government accepted the Committee’s recommendation and said the Department of Health and Social Care and the Ministry of Justice planned to publish a joint response as soon as possible.

On 12 September 2023, in answer to a parliamentary question from Tim Loughton (Conservative) asking when there would be progress, Mike Freer, Parliamentary Under-Secretary of State for Justice, said “Both the Health Minister and I are pushing this as fast as we possibly can”.