Consultation on coronial investigations of stillbirths

Closed 18 Jun 2019

Opened 26 Mar 2019


A stillbirth is a tragedy which has a profound effect upon bereaved families. We are committed to ensuring that, wherever possible we do all we can to ensure that when such a tragedy occurs, lessons are learnt and changes made to prevent avoidable stillbirths in the future.

Our rates of stillbirth are the lowest on record but they are still higher than some other comparable countries, which have succeeded in bringing rates down even further. There is much to be proud of in the year-on-year falls in the proportion of pregnancies that end in a stillbirth, demonstrating an almost constant decline since the 1980s. Nevertheless, we believe that there is still more that can be done. 

Whilst we have robust and comprehensive systems for establishing the possible causes of a stillbirth and reviewing the care that had been provided, there is room to further strengthen these processes. Although many parents are satisfied with the results of these reviews, others feel they have not always been listened to, or that they have not had access to all the facts. Still other parents are concerned that the lessons revealed in these reviews are not always put into practice.

Over the years there have been calls from bereaved parents, charities and others for a more transparent and independent process for determining the causes of, and learning from, stillbirths. It is time we considered this important and sensitive issue in detail.

Some of those calling for change have identified coronial investigations as the way to deliver an improved process, while the Chief Coroner for England and Wales has repeated his call for proper consideration of the question whether or not to give coroners powers to investigate stillbirths.

We are therefore very pleased to publish this consultation, which seeks views on proposals for introducing coronial investigations of stillbirth cases in England and Wales. This consultation has been prepared jointly by the Ministry of Justice and the Department of Health and Social Care and is an important step towards delivering the Government’s commitment to reduce the rate of stillbirths.

In addition to introducing greater transparency to the way in which stillbirths are investigated, the Government’s proposals would ensure that bereaved parents are involved at all stages of the investigation, and that any learning that can be taken from such investigations is disseminated across the health system to help prevent future avoidable stillbirths.

At the same time as the Government has been developing its proposals, a Private Member’s Bill, Tim Loughton MP’s Civil Partnerships, Marriages and Deaths (Registration Etc) Bill, has made its way through Parliament. The Bill is now subject to its Royal Assent* and will place a duty on the Secretary of State to make arrangements for the preparation and publication of a report on whether, and if so how, coroners should investigate stillbirths.

The Bill also provides a power for the Lord Chancellor to make provision, through secondary legislation, for stillbirth investigations by coroners if, following publication of that report, this is considered appropriate.

We would encourage a wide range of people and organisations to respond to this consultation because it is important that we hear and consider all points of view. We are particularly keen to hear from bereaved parents, the organisations that support them or that provide advice to pregnant women, researchers, health professionals and healthcare providers, as well as from those working for coronial services.

Edward Argar                                                              Jackie Doyle-Price


* The Civil Partnerships, Marriages and Deaths (Registration Etc) Act 2019 received Royal Assent on 26th March 2019.

Why your views matter

This consultation seeks views on proposals for introducing coronial investigations of stillbirth cases in England and Wales.


  • Citizens
  • Coroners
  • Voluntary organisations
  • Health professionals


  • Coroners