Coroners to investigate stillborn deaths
The argument put forward in this article is so compelling I think it’s worth highlighting some main points from it with a little of my own commentary:
Today, the Health Secretary announced “a new maternity strategy to reduce the number of stillbirths”. This strategy centres on the investigation of still birth deaths by the new Healthcare Safety Investigations Branch but it also included a planned change in the law to allow coroners to investigate full term still birth deaths. Currently there is no requirement for a doctor to refer a still birth death to the local coroner.
This echoes the current state of affairs not only in the UK but in most high income countries across the globe including Australia, the stillborn baby is not considered a legal entity.
A recent report by MBRACE-UK included the finding that in 8 out of 10 deaths different care might have saved the baby’s life.
We currently don’t have a similar report in Australia BUT if we did, I suspect that we would also find similar concerning rates.
Recently the Chief Coroner voiced concerns about the inadequacy of the law in England and Wales on referrals of still born deaths to coroners. There is no legal requirement for doctors to refer the death of a still born baby to the local coroner which is a lost opportunity to improve the safety of maternity care.
The situation in Australia is even worse, the Coroner has no jurisdiction for investigating stillbirth meaning that even if they wanted to the current law prevents anyone referring a stillborn death to the coroner.
This means that coroners are not routinely investigating still birth deaths and so the reasons why babies die in unexplained circumstances are not being discovered and lessons are not being learnt. Not only does an inquest bring to light the causes of deaths but it also requires coroners to make a formal Report to Prevent Future Deaths where concerns are identified. Such a report is public and sent to those with the power to make changes highlighting the practical steps that need to be taken with the intention of improving public health, welfare and safety.
These are PRECISELY the reasons why the Coroner needs to have jurisdiction over stillborn deaths in Australia too!!!
The Chief Coroner reported that discussion had commenced on considering whether stillbirths/near term deaths should be reportable cases but that any changes would be likely to require primary legislation. Today’s announcement in the House of Commons promises that these changes will be made after further consultation with the Ministry of Justice. The Health Secretary suggested in his response to questions from the House that this consultation might include considering whether or not “specialist” coroners will be needed in order to properly investigate these types of death.
Stillaware is calling for a similar change in legislation in Australia BUT we are apparently a LOOOOONG way behind the UK. So Come on Aussie come on lets also begin the process that will inevitably lead to saving more babies lives in Australia and not be left behind by countries like the UK!