Government consultation into allowing coroners to investigate stillbirths: have your say

[RowanMumsnet]

Hello

The government has announced a public consultation over a proposal to allow coroners to carry out investigations into the circumstances around stillbirths.

The Ministry of Justice says:

"Whilst we have robust and comprehensive systems for establishing the possible causes of a stillbirth and reviewing the care that had been provided, there is room to further strengthen these processes. Although many parents are satisfied with the results of these reviews, others feel they have not always been listened to, or that they have not had access to all the facts. Still other parents are concerned that the lessons revealed in these reviews are not always put into practice."

"Over the years there have been calls from bereaved parents, charities and others for a more transparent and independent process for determining the causes of, and learning from, stillbirths. It is time we considered this important and sensitive issue in detail."

"Some of those calling for change have identified coronial investigations as the way to deliver an improved process, while the Chief Coroner for England and Wales has repeated his call for proper consideration of the question whether or not to give coroners powers to investigate stillbirths."

You can read more about the consultation, and find a link to a survey for responses, here.

We'd be interested to hear what you think.

Thanks
MNHQ

We had a post-mortem after our son’s stillbirth. We did get answers and found he had a hypocoiled cord. This meant the looping was far too loose and the cord had been crushed in utero, causing catastrophic brain damage. This can happen in subsequent pregnancies so I was monitored exceptionally closely.
Having an answer was really important for us.

I'm another who supports this. My daughter was stillborn 14 years ago this July, at almost 42 weeks. A post mortem could find no cause of death. She was a good weight, 9lb 4oz, and 22.5 inches long. Placenta was fine. We were told it was like she had suffered a cot death in the womb!

Sorry to hear that Labtest7. We still have a lot to learn.

One of the saddest days of my life genuinely, was when my younger cousin's baby was stillborn. Despite us not being terribly close, I had a young baby at the time - a baby that my young cousin used to mind for me, stay overnight and feed during the night when I was utterly exhausted etc. She was born to be a Mum.

She was only 20 and it was her first baby. I still think about her little baby and the utter shock it was to me hearing of the death. I had never heard of anything like it in my life (I was never a Mumsy sort so didn't know much about pregnancy etc.).

My cousin now has 4 more children. The baby she lost was a girl. She now has three boys and a girl so 5 in total. Her daughter's middle name is her first child's name.

For something so removed from me to affect me so much, I can only imagine how it affected my cousin and her partner. At the inquest, it was like most - unexplained - just one of those things.

I 100% would support a shift to more robust questioning of what went wrong.

My heartfelt best wishes go out to everyone who has lost a baby to still-birth. It seems in some ways to be the cruellest of ways.

I lost 2 babies over 20 weeks but before 24 weeks. The loss was horrific. Yet it was classed as a miscarriage. In addition one of babies was alive in labour but I was told they wouldn't help if was born alive. That was also horrific. Any loss is horrendous but having had early MC it was totally different. Had I gone a week longer it would be officially stillbirth.. these losses around 23 weeks are not counted in the statistics. I feel they should be counted after 20 weeks like most countries.

to each and every one of you.

I had an early miscarriage, so not so far on as to be covered by this, but I know four friends who had full term stillbirths - FOUR.

That’s more people than I know who have a child with cancer, or a cleft lip, or Down Syndrome or any other condition.

If there were four road deaths at a junction over four years there would be immediate action. Four stillbirths at the one hospital don’t result in any national outrage, it was statistically ‘one of those things’ and within expected parameters.

I think any and every investigation that can be done is wise and very much in the public interest.

I would be very concerned if any consultation did not include clear protections against criminalising miscarriage.

The examples in the US are horrific.

Pinkpupz, was just about to say to you that both your losses would be classed as stillbirths in most of the world, I really think that should be the case here in the U.K. too, after 20 weeks a loss is a still birth

I think stillbirth is one of the most terrifying things about pregnancy, and all my sympathy with PPs and everyone else who has had to go through something so cruel. I think this proposal has to be a good thing as it will get answers for some people who might otherwise not have had them, and it might help to prevent future losses.

I also agree 100% with the PP who said later scans; surely money is the only reason why the NHS doesn’t scan after 20 weeks? I had GD with my pregnancies, so had several extra scans, and every time they checked the placenta; the cord; flow through the cord etc. Surely doing this at 32 weeks or so for all pregnancies would be sensible?

My concern is who is actually going to do the investigation as I doubt the coroner will have enough obstetric experience to carry out an investigation.

So either they try and do one themselves but it will be flawed and unreliable as they won't have the expertise. Or they rely on reports, etc from the obstetricians/midwives/risk team at the hospital. Which is really no different from the status quo of hospitals doing their own investigations.

So while on paper it sounds great I'm not sure when you look at it closely that it's not just a load of spin.

The government recently set up a maternity investigation bureau. Why aren't they tasked with such investigations, or at least contribute to the, They are independent of the hospitals but are made up of qualified and experienced midwives so will have more understanding of the issues than a coroner.

It's about time. A large number of stillbirths are due to medical negligence of one kind or another. My DD was officially stillborn as she was lifeless following a disastrous and unnecessary delay in me being examined. She was resuscitated and now has profound disabilities.

Stillborn babies like DD who weren't so lucky may have also been saved if correct and timely procedures were carried out. Maternity care in this country is a disgrace and needs a massive overhaul, not least the complacent and cavalier attitude of some midwives.

I predict this review will show a devastating lack of care and many unnecessary deaths caused by negligence. Something I will be glad to see happen, so that the inadequacy of the service can be exposed and something done about it and people held to account.

sashkin. There's no such thing as a 'spontaneous' stillbirth. The baby dies for a reason. It may not be preventable, but there is a reason. A stillbirth occurring following labour is no different. There is always a reason. The reason may not be anyone's fault, and may not even be preventable but many are and this scandal is going to be exposed by the report.

bird I understand that, and I don’t mean to cause offence with my phrasing. I just was just trying to differentiate between failures in care during labour (which I would be gunning for the trust over), and intra-uterine deaths at, say 28 weeks.

As I mentioned, I had a second trimester miscarriage (plus several other miscarriages) and personally would not have wanted an inquest if it had been detected a couple of weeks later. I have no objection to other people requesting one, but I would have found it traumatic to relive everything, have to stand up in court and give evidence etc, six months later. My own personal view.

I would want a post-mortem, to check for anything that could be screened for in later pregnancies. But not a full inquest.

Yes absolutely a great idea.

I think it would be a very positive thing. Help people make informed decisions about future children and help them process their grief. It'd help reduce a considerable amount of suffering.

In theory and on a population level I can see the benefits of this. However, would this mean parents lose the chance to decide whether or not a post mortem is carried out? My cousin and his wife lost their full term baby and chose not to have a post mortem. It would seem brutal to remove that choice from bereaved parents.

I lost my second son 22 weeks into my pregnancy - a 'late term miscarriage' but I had labour induced and gave birth to him so I consider that he was stillborn (a different topic to campaign for and one I feel strongly about).

Prior to his birth we were offered a post mortem and we said, absolutely, yes. When he was born I couldn't imagine anything worse than subjecting his tiny body to that so we said no.

We were fortunate in that examination of the placenta showed it had been failing for some time and this tied in with my medical history during the pregnancy so we had answers as to why we lost him.

Parents deserve to have every effort made to determine why their child died. Because a baby dies before birth doesn't make that baby less valid.

However, my professional experience includes investigating deaths of babies and children and I can only imagine the pain an enforced PM must cause to grieving parents.

The NHS Trust whose care I came under were great and I have faith that their findings were accurate. Not everyone feels this way.

Perhaps maternity bereavement care should be standardised and formalised, and this would take away the need for coroners inquests...?

Piglet my experience is similar to yours, and my feelings about this are similar too.

Absolute support it. Yes it’s true the cause may never be known, but I think if this does come in what we will find is that there were signs all was not right, but mothers weren’t listened to. Currently statistics show at least a third of all still births are preventable. It’s just not good enough. However I don’t think parents should be forced into it.

@Sashkin I'm very sorry for your loss x

I'd be a bit concerned about how intrusive a coroner's investigation into stillbirths could be. Will investigations mean parents are unable to grieve the loss of their child according to their own customs and in their own time frame? Are women's medical records going to be made available to the coroner? What if the mother doesn't consent? Could women be made to account for every bit of unpasteurized cheese they ate or for exercising too much/not enough/in the wrong way?

I totally see the need for independent investigations to ensure care was as good as it should have been. I support research projects to look into the causes of stillbirths and develop best practices and advice. I don't think a coroner's court, especially with its close relationship to the criminal justice system, is the place for it.

I'm also concerned about the cost and amount of time for investigations. Coroners' courts are already backed up as it is, aren't they?

I think it's great. Coroners can give Trusts Prevention of Future Death notices where there are system or procedure failings found. Other types of medicine are subject to this, why not maternity services?

On the concerns around addiction, the family are usually represented by a solicitor . The health trust would need hard evidence that substances were used to the extent this endangered the baby's life. I doubt a coroner would allow a clinician to make suggestions based on a mother drinking the odd glass of wine or prenatal substance use. Coroners also can't use criminal charges against any individual.

I think there's a danger the blame may be put on the mother: what she ate/ didn't eat, how much excercise she did or didn't do, whether she was in an abusive relationship and failed to leave, whether she took enough folic acid etc. In other countries women are prosecuted for having miscarriages and stillbirths and we would have to have adequate safeguards to avoid going down that route.

This is not about blame - it is about establishing the cause of unexpected death in an almost full term babies where the cause is not already established. This is what happens for anyone else with an unexpected death. I am surprised it hasn't been the case before and am glad extension of the law is being considered.