Joanna Park and Daniel Dice

17 babies die in the womb or shortly following birth every day in the UK– that’s ten times the number claimed by cot death. After their son was stillborn last September our clients Joanna Park and Daniel Dice begun to campaign for a transparent, national system for investigating stillbirths.

At the moment there is nothing close to such a system. Individual hospitals have their own procedures for recording intrauterine deaths and information is rarely shared between hospitals. With one in two stillbirths remaining unexplained[1] this is a staggering missed opportunity. How can tragedies be prevented without the chance to learn from other patients’ experiences?

The lack of a national system for investigations goes some way towards explaining why we have fallen so far behind other wealthy nations in reducing stillbirths. In April 2011 a national audit by The Lancet found the UK’s problem with stillbirth to be among the very worst in the developed world, with only France and Austria having higher incidences. 

With the NHS facing dire cuts an entirely new system might face opposition – but we already have a very effective process for unexplained deaths that could be expanded to cover stillbirths. Coroner’s inquests determine the circumstances and causes of death when they are unclear. Lessons can be learned by clinicians and policy-makers and changes can be brought about through the Coroner’s power to report to relevant bodies to demand action be taken. This creates a safer, more effective health service. However, a Coroner only has jurisdiction to investigate where a person has died, and as a stillborn child is not legally recognised as ever having lived there is no death to investigate in legal terms. 

In the case of Samuel Dice an unusual set of circumstances caused a slight exception to the rule. It was at first unclear whether Samuel died in or outside the womb and given that the cause of death was unclear the matter was referred to the Coroner for Brighton and Hove, Mrs Hamilton-Deeley who opened an inquest.  Once a post mortem confirmed this was a stillbirth the Coroner was prevented from conducting a full inquest into the circumstances of the death, but she was required to conclude her inquiry. In doing so the Coroner took the opportunity to record facts relevant to the death having heard evidence from Dr Simi George, the consultant pathologist who conducted the post mortem examination. She found that the death occurred two to four hours before the baby’s heart rate was found to be absent. The fetal heartbeat had not been checked during the previous six hours and fifty minutes of labour.

Joanna and Daniel believe simple monitoring could have saved Samuel’s life by giving the opportunity for an earlier delivery by Cesarean section. The failure to arrange for continuous monitoring of the baby’s heartbeat with a CTG machine is particularly hard for them to comprehend, as Joanna specifically reported a reduction in the baby’s movement, a known risk factor for stillbirth.  The limited scope of the Coroner’s inquiry meant that these issues could not be investigated, as they would have been in a normal inquest.

The official complaint which the couple made to the Royal Sussex has given the hospital a chance to investigate and understand what went wrong. It must be hoped this will lead to improvements in care that will save lives. But this is not the only labour ward facing problems with staff levels at peak periods. In October 2011 the Royal College of Midwives warned of a national shortage and called on the Conservative Party to fulfil its election promise to train an extra 3,000 midwives.

In the context of such a difficult clinical environment the need to understand the causes of stillbirth is even more vital. Changing the law to expand Coroners’ powers could go a long way to achieving this.

By Robert Bell

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