Written evidence from Campaign for Safer Births

Coroner jurisdiction for stillbirth


Campaign for Safer Births (CfSB) was co-founded by Nicky Lyon and Michelle Hemmington in early 2013. Nicky and Michelle were introduced to each other whilst campaigning individually following the death of their sons.

Nicky’s son, Harry was left profoundly brain damaged and later died following failings in care during term labour. During full-term labour doctors were unable to resuscitate Michelle’s son Louie and he was later registered stillborn.

Michelle and Nicky were shocked that following both these incidents, the hospital Trusts concerned were able to investigate themselves with little/no external scrutiny. The families had to undertake litigation to receive an independent assessment of their treatment.

Compare this to what would happen if a child died in other circumstances involving potential negligence – there would be independent investigation from agencies such as the Coroner service, the Health and Safety Executive and the Police.

Campaign for Safer Births has worked for over 7 years to increase awareness of avoidable harm in maternity, to campaign for independent investigations & parent involvement, for Coroner jurisdiction for stillbirth and for improvements in the safety of maternity services.

CfSB was instrumental in getting Coroner jurisdiction for stillbirth included in Tim Loughton’s Private Members Bill and the subsequent public consultation.

Michelle and Nicky are the parent representatives on the RCOG Each Baby Counts project. Nicky has worked with NHS England as a user representative for many years and currently is lay co-chair of the National Maternity Transformation Programme (MTP) Safety Workstream.

Ways to strengthen the Coroners’ role in the prevention of avoidable future deaths

Where a Coroner has been able to conduct inquests following baby death due to injury in term labour it has been instrumental in providing answers to families, in uncovering major issues, instigating improvements and preventing future deaths. The recent case of baby Harry Richford at East Kent Hospitals University NHS Trust is an example of this.

At present, Coroners are not able to investigate babies registered stillborn following term labour – even if they suspect negligence/poor care. Many Coroners are very frustrated at this situation. They feel their hands are tied.

Maternity claims make up half the cost of litigation cases with 80% of full-term stillbirths in labour being potentially avoidable (MBRRACE-UK).  By allowing Coroners to scrutinise these cases it would not only improve care and save lives but reduce the litigation costs – potentially saving hundreds of millions of pounds.

Hospital investigations for Stillbirths are often poor and parents find it extremely difficult to trust in an investigation when the hospital is investigating themselves. This can lead to parents feeling as though they have to investigate their own baby’s death which leads them to litigation as their only avenue of independent investigation. The rollout of HSIB involvement in investigating all ‘Each Baby Counts’ babies is very welcome, however the long term funding for this work and plans are unclear although HISB should never replace a coronial investigation.


For the safety of mothers and babies it is imperative that stillborn babies are given equality with other babies to ensure their deaths can be independently investigated by Coroners when required.  It is unfathomable that a baby born at, for example, 24 weeks who takes a breath but passes away could be taken to inquest yet a baby who dies during labour at full-term and is capable of living independently from the mother is not? Every other death in the NHS can be investigated by Coroners yet full-term Stillbirths are excluded when most likely these deaths are due to errors in care.  If Coroners were able to inquest full-term stillbirths this could not only prevent future deaths but also prevent brain injury as a baby who sustains this type of injury is a stillborn baby who has been successfully resuscitated.

The Report into the Morecambe Bay Inquiry (Bill Kirkup) made a key recommendation that Medical Examiners should be involved in stillbirth – this has still not yet been implemented.