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

I've been reading through the the consultation and some of it is, quite honestly, shocking.

Some elements that are being asked about:

Should the coroner take legal custody of the placenta? So women who suffer stillbirth would no longer be entitled to their own bodies.

Should the coroner, as s/he currently is, be able to compel witnesses to testify?
Can you imagine having had a stillbirth, gone through the grieving process, found the sources of comfort you find most beneficial and then being compelled to give evidence about your own behaviour and health in a transparent public forum?

Should coroners have a duty to find out when and where fetal death occurred? So women who have undergone stillbirth would need to provide details of where they were and have their medical records examined by the coroner whether they wanted to or not.

Should coroners have a duty to ascertain who the mother is? So no right to medical privacy there.

And more.

It's a huge invasion of privacy. When you read through it some of what is suggested is really, really shocking. It seems a terrible thing to force on mothers who have a stillbirth.

The purpose of the proposal is to determine the cause of death in a fully developed fetus who has survived to at least 37 weeks. Anyone who has carried a baby to this stage in pregnancy will have bonded with their son or daughter. The loss of a baby at this stage is devastating - difficult to describe or compare to bereavement of elderly relatives reaching a natural end of their life.

Almost certainly most parents will want to know what happened to help come to terms with the devastation. More, they will want to know if they are predisposed to anything that could result in a further death, and which could be avoided by changes in their care.

The placenta is a rich source of information about pathology which can lead to the death of a baby and the coroner would be able to request a medical examination of the placenta. There is no point in doing a partial examination. If it is going to be done, it should be done fully.

The coroner would only ask witnesses to speak if relevant and it states in the proposal that no witnesses would be obliged to answer questions which would lead to self-incrimation. Most parents would welcome the opportunity to contribute to the investigation. The only parents who would have to worry would be those who have committed the criminal act of "child destruction". In this case the coroner would halt the inquest and hand over to the police or the case would not make it to the coroner before the police investigation.

Most of the coroner's evidence will come from medical reports and medical statements.

The consultation document proposes that the CCSS as well as special organisations would provide support to the parents, as the sensitivity is recognised.

If a baby is born alive but dies within minutes, it will have the same status in law as an older neonate or any other person and a coroner's investigation already takes place in this situation. This proposal simply extends this to all full term babies - ie 37 weeks and beyond. This is why it is important to establish age at death.

Nettle none of which answers the question of why such a process should be compulsory for stillborn babies regardless of the mother's wishes.

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.

The consultation suggests it will take place whether the cause is known or not and whether the mother wants the investigation or not.

BoomBoom - I agree it is not clear if an investigation is proposed should the cause be known already. It doesn't for anyone else, so I don't see why it should take place in the case of a stillborn baby.

Nettle - the consultation is pretty clear that the proposal is for all babies stillborn at 37+ weeks would have a coronial investigation. See the "Registration of a stillbirth where the coroner is involved: flow chart" page.

BoomBoom - if this is what it means I would oppose it - there is no advantage to routine investigation, only where the cause is unclear.

I would support this wholeheartedly.

I had an unexplained stillbirth at 37 weeks. I still feel anguish when I think of how I was let down by incompetent midwives who didn't refer me on to a consultant after repeated episodes of reduced movements, who missed this crucial fact on the night when showing consultant low HR readings and missed opportunities to save him and insisted on sending me home when I was 2cm (and his HR was low).

For the posters asking how parents would feel if they were blamed - a coroner's court is not the same as a criminal court I don't think. One of the completely inexperienced abysmal midwives who was caring for me that morning did note on my record that I had a high BMI and this made measuring HR difficult. Although she wrote this after the stillbirth in a rushed attempt to cover up her incompetence. This was contested by the hospital's investigator during the subsequent investigation who noted "The midwife mentions the woman’s weight several times, but her BMI is not significantly raised."

Shambolic all around and the hospital did not respond to subsequent inquiries as to how they actually changed their practices based on the number of "missed opportunities" noted in the report.

Bisquick do you think all women who have a still birth should be legally obliged to go through this whether they want to or not?

No. As it stands the Coroner doesn't investigate all deaths in the UK. I don't know the procedure for which deaths are referred to the Coroner. There are presumably safeguards in place to prevent abuse and overloading of the system. But one-half of stillbirths in the UK are unexplained. And I think that's a ridiculous figure for a country that already has a ridiculously high rate of stillbirths.
I can also imagine this may be piling on trauma on parents at an already impossibly difficult time - so there should be some parental opt-in perhaps? Much like how we had to opt-in to whether we wanted a post-mortem.

I find some parts of the consultation uncomfortable - but the same standards apply to children born alive - and it's only a matter of a few minutes in some cases distinguishing one from another, no? And yet we don't see egregious overstepping by the Coroner in those cases currently. Not sure what warrants the fears of a US-style epidemic of parental blaming (if there even is one).

The suggested procedure in the consultation is that all stillbirths that are thought to be at 37 weeks or later would be referred to the coroner. And while there needs to be coronial investigation for children born alive that is because there are legal questions for children born alive that, because we have to have a cut off somewhere, do not apply to stillborn children. The coroner's court could not make the same findings for a stillborn child that it could for a child born alive because the law does not give a stillborn child personhood. While we don't hear papers standing up for the rights of parents whose child dies soon after birth, that doesn't mean they aren't distressed by coronial investigations. Many people are distressed by coronial investigations into loved one's deaths, especially those whose cultural practices and rituals for grieving are interrupted by the process.

I'm also curious why anyone would think a lawyer looking individually at cases rather than well designed scientific research is likely to find out the reasons behind the half of unexplained stillbirths.

But @BoomBoomsCousin, forgive me if I'm wrong, as it currently stands, parents have to rely on hospitals conducting their own investigations and some, understandably, are suspicious of the results of these - as pp have experienced.

A death that comes under the coroners scrutiny is investigated by the police on the coroners behalf. So it's not just a lawyer, it's an independent police investigation backed by additional processes not carried out by hospitals.

My heart goes out to all affected by this type of loss, I can’t imagine the pain...
I think that grieving parents should be given the choice to have their loss reported and investigated by the coroner.
Maybe I’m missing an important point of view here, not having suffered this loss, but I think it should be an opt-out format, to ensure that those parents who do want to report it have more support and don’t have to suddenly try and fathom how get the process started.

Pig I absolutely agree that patients should have access to some sort of independent investigation if they are unsatisfied by the hospital’s when things go wrong (and not just for deaths). But this is a very different thing. This is a compulsory process that would happen regardless of the how the mother feels or how the hospital has reacted. It is bureaucratic and legal focused not medical/health focused.

There must be a better way of providing women who go through stillbirth with transparency and as many answers as possible than a compulsory legal process that they have no rights over.

Then is this the best option currently until a better alternative can be found?

I'm not necessarily sure I know which camp I fall in, but I'm very interested in hearing other people's views.

How often do coroners' investigations into other hospital deaths satisfy the loved ones of those who died? Especially for babies who die soon after birth? Has it got us anywhere much with lowering the rates of those deaths?

Actually you’re right BoomBoomsCousin and you made me think about it in a different way. I think some of us instinctively feel like this would be better than a hospital’s inquiry and there’s no guarantee that it is. It would just be one more intrusive process with potential to cause much more upset.

Reflecting on it some more I was relatively satisfied with my hospital’s investigation. It was heartbreaking but fairly candid about the ways we were let down and the missed opportunities. A deep down part of my lizard brain really just wants to scream at some of the midwives that day, and have them actually apologise and acknowledge their mistakes, but for all I know they’re walking around feeling haunted by that day and none of this will bring back my boy.

Anyway, I’ve actually changed my mind I think. It’s such an emotive topic though..!

It is an emotive topic, losing a child is tragic any time but the feeling of not knowing what happened or feeling that the hospital has covered things up can make it harder to accept and move on.

I am fully behind a push for independent medical investigations into stillbirths at the parents’ request and also into more funding for medical research into the causes. I just don’t see this process improving things and I see some really bad downsides to it.

It sounds very interfering and with a lot of downsides for parents.

This is slightly off at a tangent, but still relevant. Hope the link works lnkd.in/ec5MvJx