September 2016 saw the first ever stillbirth inquest in Northern Ireland (BBC News, 2016). Ever since Cara Rocks was stillborn in 2013, her parents have been seeking answers surrounding her death. During the inquest, the coroner said that lessons had been learnt by the hospital and that care had improved at the maternity unit. The coroner also praised the parents for seeking answers regarding their daughter's death.
There have been cases in the UK where coroners have investigated perinatal deaths, usually at the request of the parents following inadequate local investigations (Sands, 2016). These cases usually come about when there have been ‘signs of life’ present at birth, and are not classified by UK law as stillbirths, but neonatal deaths. The definition of a stillbirth in England and Wales is contained in the Births and Deaths Registration Act 1953 section 41, as amended by the Stillbirth (Definition) Act 1992 section 1(1), and is as follows:
‘A child which has issued forth from its mother after the 24th week of pregnancy and which did not at any time breathe or show any other signs of life.’
The Coroners and Justice Act 2009 does not cover stillbirths as defined in the Births and Deaths Registration Act 1953. This is because the legal definition of ‘person’ needs to have been born alive with ‘signs of life’.
The purpose of an inquest is not to apportion blame, but to find out what happened and how the death occurred. All bereaved parents deserve to know why their baby has died, and whether failings in care contributed to their baby's death. Stillbirth charity Sands wants to see the Ministry of Justice broaden the powers of coroners so that they are able to investigate a stillbirth, should parents believe that the hospital's internal investigation process has not adequately reviewed their baby's death or answered specific questions relating to their care. It would not always be appropriate for an inquest into a stillbirth to take place—for example, in the case of a feticide or a death following a known severe congenital abnormality. An inquest can also be a lengthy, distressing process for all involved.
The Royal College of Obstetricians and Gynaecologists' (RCOG) Each Baby Counts campaign is trying to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour. The RCOG has been collecting data since 2015 on intrapartum stillbirths over 37 weeks' gestation or early neonatal death (when a baby dies within the first week of life). However, these data are dependent on the local unit uploading information to the RCOG database, and the data uploaded has to meet the Each Baby Counts inclusion criteria. Currently, Each Baby Counts is not reviewing antepartum stillbirths.
At a local level, parents should be invited to be involved with investigations with the opportunity to ask specific questions about their care. To ensure the robustness of the report, the staff investigating the incident should have training on incident report writing, with the final report reviewed by senior members of the maternity team.
Following national scandals at Mid Staffordshire NHS Foundation Trust and University Hospitals of Morecambe Bay NHS Foundation Trust, the NHS is working hard to learn from incidents, with a culture of openness and transparency. Trusts have a statutory duty under the duty of candour to be honest and open with service users when things go wrong. The duty of candour process is a national commitment to openness, learning and improving care within the NHS.
‘The term “unexplained stillbirth” is used too widely; there is always a reason for stillbirth, we just don't always know what it is’
The Morecambe Bay investigation raised concerns over the quality and level of local investigations into stillbirths, with some deaths having no investigation at all. All stillbirths should have a robust local investigation that is shared with the parents. Currently, there is no national regulation to scrutinise why a stillbirth has occurred. It is important to try to find out why a baby has died, as this will help to improve care, identify adverse trends and prevent more babies dying. It would also allow Trusts and local clinical commissioning groups the opportunity to improve and tailor care to a specific group of women at higher risk of a stillbirth.
The term ‘unexplained stillbirth’ is used too widely; there is always a reason for stillbirth, we just don't always know what it is. I agree with Sands that we should work towards having national perinatal surveillance that reviews all infant deaths from 22 weeks to 28 days of life. This would give every baby a voice, even if its cry is silent.