Timeline - The Key Dates
2019 – Parliament Acts - requiring a report on coronial investigation of stillbirths.
2019 - Consultation Completed.
2024 - Factual Summary of Consultation Responses Published.
2026 - Baroness Amos Maternity & Neonatal Investigation says the MOJ Report should be published without further delay.
2026 – That report has still not been delivered.
This timeline summarises the legal framework, policy developments and correspondence relating to coronial investigation of stillbirths in England.
1861
Offences Against the Person Act 1861
The Offences Against the Person Act created criminal offences relating to attempts to procure miscarriage. These provisions formed part of the legal framework governing pregnancy and unborn children in England and Wales for more than a century.
1929
Infant Life (Preservation) Act 1929
This Act introduced the criminal offence of child destruction, applying where a person intentionally destroys the life of a child capable of being born alive before it has an independent existence.
1967
The Abortion Act established the legal framework for termination of pregnancy in Great Britain, setting out the conditions under which a pregnancy may be lawfully terminated.
1992
Still-Birth (Definition) Act 1992
This Act defines stillbirth in law as:
a child born after 24 weeks’ gestation who did not breathe or show any other signs of life after birth.
This definition determines whether a death falls within the jurisdiction of a coroner.
National maternity policy
2015
National ambition to halve stillbirths announced
Health Secretary Jeremy Hunt announced a national ambition to halve the rates of stillbirth, neonatal death, maternal death and brain injury occurring during or soon after birth by 2030.
Each Baby Counts programme launched
The Royal College of Obstetricians and Gynaecologists (RCOG) launched the Each Baby Counts programme to analyse cases of stillbirth, neonatal death and severe brain injury occurring during labour.
For research purposes, the programme focused on babies born at or after 37 weeks’ gestation, allowing the analysis to avoid known confounding factors associated with prematurity.
The threshold was used as a research classification and was not intended to determine which deaths should receive investigation.
2017
Stillbirth reduction target brought forward
The Government brought the ambition forward, stating the aim was now to halve stillbirths and neonatal deaths by 2025.
HSIB maternity investigation programme established
The Healthcare Safety Investigation Branch (HSIB) began conducting independent investigations into certain maternity incidents in England.
The investigation programme adopted the 37-week threshold used in the Each Baby Counts research criteria when determining which cases fell within scope.
This marked a shift in the use of the threshold, from a research boundary to a gateway determining which cases would be investigated.
Parliamentary action
26 March 2019
Consultation on coronial investigation of stillbirths
Following the Civil Partnerships, Marriages and Deaths (Registration etc.) Act 2019, the Government launched a consultation on whether coroners should investigate stillbirths.
The consultation included discussion of whether investigation might apply to stillbirths occurring after 37 weeks’ gestation.
This threshold had previously appeared in research and investigation frameworks but does not appear in the legislation itself.
The Act received Royal Assent.
Section 4 places a statutory duty on the Secretary of State to:
make arrangements for the preparation and publication of a report on whether, and if so how, coroners should investigate stillbirths.
26 March 2019
Government consultation launched
The Ministry of Justice and Department of Health and Social Care launched a consultation on whether coroners should investigate stillbirths.
26 May 2019
The Act came into force two months after Royal Assent.
18 June 2019
Consultation on coronial investigations of stillbirths formally closed.
10 September 2019
The consultation document stated that the Government response was expected to be published by this date.
No response was published.
7 December 2023
Consultation summary published
The Government published a document titled “Factual Summary of Consultation Responses”.
The document summarised consultation responses but did not set out a Government policy decision.
19 March 2024
Westminster Hall debate – Baby Loss: Coroners
Members of Parliament raised concerns regarding the continued delay in implementing the section 4 report.
2024
Saving Babies’ Lives – 2024 Progress Report
The Saving Babies’ Lives Progress Report 2024, produced by the Sands and Tommy’s Joint Policy Unit, reported that in 2022–23 more than 800 babies who died may have survived with better care.
July 2024
Change of Government
A new Government was formed following the General Election.
No substantive progress on the section 4 duty was announced.
Investigation developments
June 2025
Maternity and Neonatal Investigation announced
Initial draft Terms of Reference did not include consideration of coronial oversight of stillbirths.
September 2025 - Ministry of Justice position
Freedom of Information requests to the MOJ about work relating to coronial investigation of stillbirths were refused on the basis that policy was under development.
2025
Stillbirth reduction target missed
The ambition to halve stillbirths and neonatal deaths by 2025 was not achieved. While some improvement in outcomes was recorded, the national target itself was missed by a significant margin.
Terms of Reference published
Maternity and Neonatal Investigation – Terms of Reference
The Government published the Terms of Reference for the national Maternity and Neonatal Investigation (MNI).
A workstream considering coronial involvement in stillbirth was included.
However the Terms of Reference introduced a gestational threshold of 37 weeks, described as “late-term stillbirth”.
Under English law, stillbirth is defined as occurring after 24 weeks’ gestation.
The 37-week threshold does not appear in the legal definition of stillbirth and had previously arisen in research and consultation contexts.
Correspondence with Government
30 September 2025
Letter sent to the Secretary of State for Justice raising concerns on behalf of families affected by stillbirth regarding the continued absence of the section 4 report.
Letter to Secretary of State for Justice (redacted)
7 October 2025
Response from Baroness Amos regarding concerns raised about the use of a 37-week threshold in the Terms of Reference for the National Maternity and Neonatal Investigation.
The Chair confirmed that the investigation methodology would include a workstream examining the legal framework for coronial involvement in stillbirth and that evidence collection would not be restricted to 37 weeks.
Letter from Baroness Amos (redacted)
October 2025
Concern raised regarding the continued wording of the published Terms of Reference.
While the Chair confirmed that evidence gathering would not be restricted by gestation, the published Terms of Reference continued to refer to coronial involvement in “late-term stillbirths (37 weeks or later)”. Concern was raised that the Terms of Reference form the formal record defining the investigation’s scope and therefore the wording should be corrected.
13 November 2025
Formal complaint response issued by the investigation team regarding the wording of the Terms of Reference.
The response confirmed that amendments to the Terms of Reference ultimately lie with the Chair of the investigation and the Secretary of State for Health and Social Care, and that the complaint had not been upheld.
Complaint response from the investigation team (redacted)
17 December 2025
Independent third-party administrative review of the complaint conducted by a Government Legal Department reviewer.
The review confirmed that the Terms of Reference had been approved by the Secretary of State and that the complaints process does not provide a route to amend the investigation’s design.
Independent third-party review outcome (redacted)
Follow-up letter from the independent reviewer (redacted)
09 February 2026
Letter received from the Secretary of State for Justice stating that the Ministry of Justice intend to communicate their position following the Maternity and Neonatal Investigation report due Spring 2026.
Letter from Secretary of State for Justice (redacted)
24 February 2026
Letter sent to the Secretary of State for Justice raising concerns on behalf of families affected by stillbirth that the statutory duty was being delegated to a non-statutory review within a different department.
Letter to Secretary of State for Justice (redacted)
Public discussion
26 February 2026
Maternity and Neonatal Investigation – Insights Report
The report stated that the investigation had heard accounts from families who believe babies who showed signs of life were recorded as stillbirths.
It noted the perverse incentive created where deaths before a first breath may attract less scrutiny.
February 2026
Media coverage following the report highlighted that families of stillborn babies are not entitled to independent coronial investigation.
Former minister Tim Loughton, whose Private Member’s Bill introduced the section 4 duty, confirmed publicly that the absence of coronial oversight for stillbirth remains the current legal position.
5 March 2026
A Written Parliamentary Question was tabled by Sir Gavin Williamson MP asking the Secretary of State for Justice when the report required under section 4 of the Civil Partnerships, Marriages and Deaths (Registration etc.) Act 2019 will be published, and what assessment has been made of the impact of the delay on accountability, learning and the prevention of future deaths?
Written Parliamentary Question - UIN 118173
18 March 2026
Written Parliamentary Questions submitted by Sir Gavin Williamson MP regarding:
•
Whether an assessment has been made of the impact of the delay in reporting on bereaved families - UIN 121720
•
Whether it is planned to apply a 37-week gestation limit to coronial oversight, and the statutory basis for this - UIN 121721
•
Whether the Maternity and Neonatal Investigation will report to Parliament - UIN 121722
•
Whether responsibility for Section 4 reporting lies with the Ministry of Justice - UIN 121723
The Ministry of Justice confirmed in a letter to Sir Gavin Williamson MP dated 18 March 2026 that it is treating coronial investigation of stillbirths as a cross-departmental matter with the Department of Health and Social Care, on the basis of its role in maternity policy.
This raises the question:
Why access to independent legal investigation is not treated solely as a matter of justice.
26 March 2026
MoJ responded to four Parliamentary Questions - seven years to the day after the Act was passed.
Each received the same answer.
No assessment of harm. No legal basis for 37 weeks. No accountability.
This position contrasts with earlier statements that policy development was ongoing within the Ministry of Justice.
7 April 2026
Correspondence from the Chair of the Maternity and Neonatal Investigation confirms that the Investigation is not limited to 37 weeks, and considers stillbirth from 24 weeks onwards.
The Chair also confirms that she is not responsible for Parliamentary Questions or the answers given by Ministers.
This sits alongside Parliamentary answers and published Terms of Reference which continue to rely on a 37-week threshold.
Letter from Chair of the Maternity and Neonatal Investigation (redacted)
14 May 2026
Written Parliamentary Question submitted by Sir Gavin Williamson MP regarding:
21 May 2026
Following the appointment of the new Parliamentary Under-Secretary of State at the Ministry of Justice, No Breath Required wrote to the Minister to brief her on the issue and request progress fulfilling the statutory duty contained within Section 4 of the Civil Partnerships, Marriages and Deaths (Registration etc.) Act 2019.
The correspondence highlighted the continuing absence of a published Section 4 report, apparent inconsistencies between Freedom of Information responses and Parliamentary answers, and the continued deferral of a statutory justice issue to the non-statutory Maternity and Neonatal Investigation.
Letter to Catherine Atkinson MP, Parliamentary Under-Secretary of State, Ministry of Justice
Not acknowledgement or response was received.
10 June 2026
Written Parliamentary Question submitted by Lord Kamall regarding:
11 June 2026
Written Parliamentary Question submitted by Lord Kamall regarding:
15 June 2026
Written Parliamentary Question submitted by Lord Kamall regarding:
•
To ask His Majesty's Government what discussions they have had with the Chair of the National Maternity and Neonatal Investigation regarding the threshold from which coronial involvement in relation to stillbirths should apply, and specifically about whether that threshold should be (1) 24, or (2) 37, weeks. - HL 945
•
To ask His Majesty's Government what independent investigatory route exists for families affected by antepartum stillbirth or stillbirth before 37 weeks' gestation other than a Perinatal Mortality Review Tool review conducted by the Trust involved in care. - HL 946
30 June 2026
National Maternity and Neonatal Investigation Final Report
The final report of the National Maternity and Neonatal Investigation was published.
Regarding coronial oversight of stillbirths, Baroness Amos recommended that the Government publish its response to the 2019 consultation on coronial investigations of stillbirths without further delay.
The report recognised that families need a clear route to independent answers following a stillbirth, whether through coronial investigation or another appropriate process.
It also recommended better alignment between investigations and reviews, so that families are not required to repeatedly recount their experiences to multiple organisations.
8 July 2026
Written Parliamentary Question submitted by Lord Kamall regarding:
15 July 2026
Whilst writing on another matter, James Murray MP, Secretary of State for Health and Social Care, confirmed that policy work had previously been undertaken regarding the duty to report under the 2019 Act.
He also confirmed that the Government had committed to delivering the action recommended by Baroness Amos, although no timescale was given.
This is the only confirmation received from Government that any policy work had been undertaken and that the issue had not stood still.
Letter from James Murray MP, SoS Health and Social Care
20 July 2026
A new Government was formed under the Rt Hon Andy Burnham MP as Prime Minister.
Alex Norris MP was appointed Lord Chancellor and Secretary of State for Justice.
No Breath Required wrote to the new Secretary of State for Justice to brief him on the unfulfilled statutory duty and the recommendations of the National Maternity and Neonatal Investigation.
Briefing Letter to New Secretary of State
The letter was sent by email and recorded delivery. No acknowledgement or response has yet been received.
18 August 2026
Responsibility for coroners was confirmed to sit within the portfolio of Under-Secretary of State Alex Davies-Jones MP
26 August 2026 - 7 Years 5 Months after Royal Assent
The letter stated that MoJ and DHSC had agreed with Baroness Amos’s recommendation to respond to the 2019 consultation, and that Government remained committed to publishing its response ‘as soon as possible’. No timetable was provided.
27 August 2026
28 August 2026
No Breath Required responded to the Parliamentary Under-Secretary of State for Justice , asking the Ministry of Justice to confirm whether it considers the statutory duty under section 4(3) of the 2019 Act to remain outstanding, whether the February 2024 factual summary constituted the required report, and whether the five-year period in section 4(6) has begun. The letter also highlighted our position that the coronial jurisdiction issue is seperate from my health based investigation reforms.
8 September 2026
The Chief Coroner's Office responded to NBRs letter confirming that the Chief Coroner met with the authors of the Baroness Amos Investigation, however as decisions regarding the implimentation of recommendations from the report are matters for Government the Chief Coroner is unable to provide further comment.
Present position
2026
More than seven years after the consultation closed, the report required by section 4 of the Civil Partnerships, Marriages and Deaths (Registration etc.) Act 2019 has still not been presented to Parliament.
The Government commissioned National Maternity and Neonatal Investigation findings recommended that the Government fulfills its statutory duty without delay.
See the briefing for a short overview of the issue, the law and the change being sought.