Bereaved families are demanding that the government states its position on what role, if any, coroners should play investigating stillbirths. It has had a statutory obligation to prepare and publish a report on this since 2019, making it now six years overdue. In a letter sent to the Justice Secretary, David Lammy, exclusively seen by the New Statesman, families of “babies who were born without taking a breath or showing signs of independent life” argue that current arrangements mean “the timing of their baby’s final heartbeat determines whether justice is possible”.
At the moment, there are limited opportunities for families whose babies are stillborn to gain answers to what happened to their children. Stillbirths are not allowed a coroner’s investigation in England or Wales. Maternity and Newborn Safety Investigations (MNSI) will only investigate stillbirths of babies who are over 37 weeks at the time of death and who have died during labour and before birth (intrapartum stillbirth). Families of babies who die before 37 weeks or before labour starts are only able to access investigations carried out by the hospitals where the deaths occurred. Families say these are “inadequate” and amount to individual hospital trusts investigating themselves.
The letter, supported by two dozen families, argues the current system is “perverse” and “creates a cruel inconsistency whereby a baby who lives briefly after birth is afforded coronial oversight, but a baby who dies moments earlier, before taking a first breath, is not”. This leads, they say, to “the untenable situation in which poorer care, resulting in an earlier death, attracts less scrutiny”. The signatories say that the current system does not count their children as people.
In 2017, the then Conservative government announced its intention to look into giving coroners powers to conduct investigations into stillbirths. The Civil Partnerships, Marriages and Deaths (Registration etc) Act 2019 later placed a statutory duty on them to do so. Section 4 of the act, which received royal assent on 26 March 2019, stated: “The Secretary of State must 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 act insisted the government also “must publish the report”. A consultation was quickly opened, and closed in June 2019, with more than 300 submissions. Six years on, there is no sign of any report, nor a government position statement.
The letter, sent to David Lammy and copied to the Health Secretary, Wes Streeting, points out that it took the last government five years (until February 2024) to even publish the findings of the consultation. At the time, ministers explained the work had been “paused” by the Covid-19 pandemic. Responses to the consultation had been “complex”, the government said, with some supportive and others against proposals that coroners should investigate stillbirths (as would be expected in a consultation on any topic). On the one hand, as a bereaved family member explained, “It is important for parents to feel completely confident that the investigation is run by someone completely unbiased and impartial, especially when there is concern there may have been substandard care.” On the other, as an obstetrician who opposed the proposals told the consultation, there are “already systems in place” that allow for the investigation of stillbirths. The government decided simply to publish a summary of what others had said, noting that a “further statement” would be issued setting out a final position. Fast-forward 18 months – and a change in government – and there has been no progress.
Campaigners for a change in the law now accuse Labour of deferring the issue. Freedom of Information responses sent in September, and shared with the New Statesman, show the government citing the ongoing independent investigation into NHS maternity and neonatal care, chaired by the Labour peer Valerie Amos, as a reason to delay publication. The government would “want to ensure that [its] final conclusions on coronial investigations of stillbirths reflect any relevant recommendations the independent investigation may make,” the Department for Health and Social Care stated.
In a separate response, the Ministry of Justice refused to provide any information held about work undertaken on the topic in the last two years. While there was a public interest in releasing the information, it said, the ability for officials and ministers to be able to openly discuss matters relating to the development of government policy trumped this. “We will not stand by while this statutory requirement is allowed to stall any longer,” the families’ letter states. “You do not need the Amos Review to confirm that NHS investigative processes are flawed, this has been documented repeatedly,” it continues, demanding the government publish its full response and position by the end of the year.
Michelle Welsh, the Labour MP for Sherwood Forest, who is chair of the All-Party Parliamentary Group (APPG) on Maternity and vice-chair of the APPG on Baby Loss, told the New Statesman that she fully supported an extension of the powers of coroners to investigate stillbirths, describing the current system as “unjust”. “This isn’t just a few families”, she said, “thousands of families” had been impacted and there was “a duty to get answers” into how and why their babies died. While fully supportive of the Amos rapid review and the government’s new national maternity task force, Welsh insisted these were separate issues to that of coroners’ oversight. The latter, she said, was a legal obligation. “It’s a real, obvious change that needs to happen,” she argued. “It’s morally right, but also it’s right because how do we improve our maternity services unless we really know what is going wrong and how we fix it.” Welsh, whose own experiences giving birth are being considered by the independent inquiry into Nottingham maternity services, said this was a government of both change and morals. The law not only needed changing, she said, but “it needs to happen quickly”.
A government spokesperson said: “We recognise the profound grief experienced by these families. Our thoughts are with all those affected by these tragic losses. The independent investigation into NHS maternity and neonatal care, chaired by Baroness Amos, may wish to consider the overall approach to investigations more broadly, and we will carefully consider its findings and respond in due course.”
[Further reading: At Labour conference, the main character was Farage]
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