Stillbirth: a neglected tragedy?
June 7, 2018
We have one of the worst rates in the developed world, with the death regularly attributed to a poor quality of care, what is being done?
A stillborn child is “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”. UK stillbirth rates remain high compared with many similar European Countries with the NHS reporting that stillbirth happens in about 1 in every 200 births in England. One of the major challenges to preventing stillbirth is the lack of information, first that the death has happened and second about why that death has happened.
As the law stands, there has to have been independent life before the coroner has jurisdiction to investigate a death. There have been calls for the law to change, including by Sands, the stillbirth and neonatal death charity, and in Parliamentary debate. In Northern Ireland, the position is different; a landmark decision in 2013 by the Northern Ireland Court of Appeal held that coroners do have jurisdiction to carry out an inquest on a child that had been capable of being born alive.
The Morecambe Bay scandal
Joshua Titcombe was one of 11 babies who died while under the care of hospitals within the Morecambe Bay NHS Trust. His father, James, was unhappy with the care and treatment he had received and campaigned to find out why he had died. The Department of Health commissioned an independent review in which Dr Bill Kirkup set out his conclusions that there had been missed opportunities at “almost every level” which meant poor clinical care was not investigated leading to preventable deaths. Improper investigation of incidents led to a failure to identify underlying problems. There was no attempt made to escalate knowledge to the level of trust executives and the board following investigation. One might argue that had the deaths of those stillborn children been reported to the Coroner, the magnitude of the problem may have been realised earlier.
In March 2014 Clara was born at Warrington Hospital but following attempts at resuscitation, her mother was told she was stillborn. Clara’s mum, Caroline, carried out her own investigations and found records from 5 different staff members identifying a heartbeat immediately before delivery and a faint heartbeat 28 minutes into resuscitation. Nicholas Rheinberg, the then Coroner for Cheshire, applied to the Chief Coroner for permission to hold an inquest, which was granted. It was said by the family that the; ‘coroner’s inquest, we believe, prompted quick action to meet recommendations made by other investigations’ thereby improving processes and avoiding deaths in similar circumstances.
On 28 November 2017, Health Secretary, Jeremy Hunt, made a statement to the House setting out the Government’s strategy to improve safety in NHS maternity services. From April 2018, the Healthcare Safety Investigation Branch (HSIB) will investigate every case of a stillbirth, neonatal death, suspected brain injury or maternal death notified to the Royal College of Obstetricians and Gynaecologists (RCOG) Every Baby Counts programme, which it was said would amount to around 1,000 incidents per year. This programme is to be rolled out over the next year.
This programme only considers cases from 37 weeks gestation, which some may argue is simply not enough. Some may ask why we do not have an approach like that used in Northern Ireland; to investigate the death of those babies who were capable of being born alive.
The onus falls on the NHS to report every case and for the HSIB to implement change and disseminate learning. Only time will tell whether this will help reduce the number of tragic stillbirths.
Sara is a personal injury and clinical negligence barrister at Exchange Chambers, recommended as a leading individual in The Legal 500 2017. Sara also sits as an Assistant Coroner.