Extend medical examiners to stillbirths

106. We accept these recommendations in principle. The medical examiners system has been trialled successfully in a number of areas across the country. We will soon be publishing a report from the interim National Medical Examiner setting out the lessons learned from the pilot sites. 107. The Government remain committed to the principle of these reforms. Further progress will be informed by a reconsideration of the operation of the new system in the light of other positive developments on patient safety since 2010 and by a subsequent public consultation exercise on regulations required to introduce a medical examiner system nationally in England. 108. Medical examiners would scrutinise all deaths except for stillbirths (for legal reasons) and any death that requires a coroner investigation. However, the MBRRACE confidential enquiries provide independent scrutiny of all maternal deaths and topics related to stillbirths and neonatal deaths, which is sufficient to learn national lessons for improvement of care.

This recommendation was accepted in principle by the previous Government but has not been taken forward.

As set out in response to recommendation 39, the new statutory medical examiner system was rolled out across England and Wales from 9 September 2024 to provide independent scrutiny of non-coronial deaths, and to give bereaved people a voice. However, as set out in the Government response at the time, there is no provision for the medical examiner system to become involved in the certification for stillborn babies and therefore this recommendation was not accepted. This is because the functions of medical examiners, as set out in the Coroners and Justice Act 2009, are limited to scrutinising causes of death. Stillborn babies are not legally classified as having died because Common law does not see this as a death, as they were not born alive.

Section 4 of the Civil Partnerships, Marriages and Deaths (Registration Etc) Act 2019 places a duty on the Secretary of State of Health and Social Care to make arrangements for the preparation of a report on whether, and if so how, the law ought to be changed to enable or require coroners to investigate still-births. The previous Government (DHSC and the Ministry of Justice) jointly consulted on proposals to provide coroners with new powers to investigate term stillbirths in 2019. In 2023, a factual summary of responses to the consultation was published.

There are other mechanisms through which still births are reviewed and investigated.

The Maternity and Newborn Investigations Programme conducts independent investigations of specific perinatal deaths, including term intrapartum stillbirths, and neonatal deaths of all term babies born following labour when the baby died within the first week of life (0-6 days) of any cause. The Programme was originally established as a part of the Healthcare Safety Investigation Branch (HSIB). The work of the HSIB transferred to the Health Services Safety Investigations Body (HSSIB) following the Health and Care Act 2022. As the Act did not make provision for maternity investigations under HSSIB, and to ensure the continuation of independent maternity investigations, the programme transitioned into the CQC in October 2023 and became known as the Maternity and Newborn Safety Investigations (MNSI) programme.

The PMRT supports Trusts to carry out standardised perinatal mortality reviews across NHS maternity and neonatal units in England. The PMRT is used to investigate a wider remit of cases, including all stillbirths where the baby is born from 24+0 weeks gestation showing no signs of life, or if the gestation is not known, where the baby is over 500g.

Medical examiners were introduced on a non-statutory basis from 2019 to provide independent scrutiny of the causes of all non-coronial deaths, to support the appropriate direction of deaths to the coroner. This includes neonatal death.

Medical examiners have been introduced on a non-statutory basis from April 2019 to scrutinise all non-coronial deaths and ensure the right deaths are referred to coroners. This includes neonatal death.

The independent investigation into National Health Service maternity and neonatal care led by Baroness Amos set out in its terms of reference that it will look to understand the potential role of coroners in the investigation of late term stillbirths and identify mistakes which would help prevent future deaths. We want to ensure that the Government’s final conclusions on coronial investigation of stillbirths reflect any relevant findings and recommendations when the independent investigation makes. We will carefully consider next steps following the publication of the final report.

Department of Health response (July 2015):

Accepted in principle.

“The medical examiners system has been trialled successfully in a number of areas across the country …

Medical examiners would scrutinise all deaths except for stillbirths (for legal reasons) and any death that requires a coroner investigation.

However, the MBRRACE confidential enquiries provide independent scrutiny of all maternal deaths and topics related to stillbirths and neonatal deaths, which is sufficient to learn national lessons for improvement of care.” (p. 94)

Hansard – September 2023 “We have already committed to moving medical examiners to a statutory basis and will table secondary legislation on that shortly. It will ensure that deaths not reviewed by a coroner are investigated in all medical settings, in particular extending coverage in primary care, and will enter into force in April.” (col 36-37)

However, the Government is yet to publish its decision about whether to include stillbirths within the remit of medical examiners, following a consultation which closed in 2019.