The current position
In England, whether a baby’s death can be independently investigated by a coroner may depend on whether the baby took an independent breath.
If a baby is born alive and dies shortly afterwards, a coroner can investigate the circumstances of that death.
But if the same baby is stillborn, a coroner has no jurisdiction to investigate.
The investigation gap
This creates a gap in oversight at the point families most need independent scrutiny, where serious concerns about care may exist but no independent authority is able to examine the circumstances.
A stillbirth may follow concerns during pregnancy or labour, concerns about decisions made, missed opportunities, or the interpretation of monitoring and escalation. But even where those concerns exist, families have no route to an independent investigation by a coroner.
Instead, concerns are typically examined through healthcare-led review processes. These processes can identify learning and make recommendations, but they are not coronial investigations and they do not provide the same form of independent judicial scrutiny.
In some circumstances external investigations may also take place, for example through national maternity investigation programmes or regulatory processes. These investigations can provide valuable learning. However, they are not conducted by a judicial authority, they do not operate under coronial powers, and they do not provide the same form of independent public scrutiny as an investigation by a coroner.
Where a baby dies before 37 weeks’ gestation, families are typically afforded no independent review beyond clinicians at the Trust where the alleged harm occurred.
The national Maternity and Neonatal Investigation has heard from families who believe their babies showed independent signs of life, but where clinicians determined that no independent breath occurred and the death was registered as a stillbirth.
The campaign is also aware of families who have questioned whether once it became apparent that delivery complications had become severe or unsurvivable, decisions about the timing or method of delivery may have affected the likelihood of an observed breath, and therefore the possibility of coronial involvement.
Why this matters?
This gap creates two different routes to scrutiny for outcomes that may be separated by minutes.
It means that in some cases serious concerns about care cannot be examined through a process that is independent of the healthcare system that provided that care.
It also means families may be left without answers, without a clear account of what happened, and without confidence that concerns have been examined transparently.
When the circumstances are serious, unexpected, or disputed, families should not be denied independent investigation because a baby did not take a breath.