A new report published by respected law firm Tees has revealed startling disparities in stillbirth rates across UK NHS Trusts. The report also found significant variations in Trusts’ policies with regards to referring neonatal deaths to a Coroner.
Fifty-six percent of the Trusts approached for information by Tees responded to the FOI request, with 44% either failing to respond altogether or failing to do so within the 20 working day deadline set out in the Freedom of Information Act 2000. This patchy response and the lack of enforcement action against Trusts who fail to respond to FOI requests means that some Trusts may be concealing even more concerning results.
Almost 10 years after Jeremy Hunt (then Secretary of State for Health) pledged to reduce stillbirths and neonatal deaths by 50% by 2030, the data received and published by Tees shows the wide disparities in Trusts’ progress towards this aim. Whilst some are already hitting this target, others continue to report stillbirth rates many times higher than the 2030 target of 2.3 per 1,000 births.
For context, this target stillbirth rate still trails behind the rate recorded for a number of countries across the globe in 2021, including Japan (1.58%), Iceland (1.79%), Singapore (1.86%), Denmark (1.91%), Estonia (1.93%), Finland (1.94%), as well as Norway, Spain, Belarus, Italy, Netherlands and Portugal, all of which have a stillbirth rate of less than 2.25%.
Patchy performance highlights ‘postcode lottery’
The significant variation in stillbirth rates between Trusts highlights the ‘postcode lottery’ faced by expectant parents when it comes to receiving high-quality maternity care. For example, Barts Health NHS Trust in London reported stillbirth rates ranging between 4.98 and 18.05 deaths per 1,000 births (between 0.5% and 1.81%). The most recent figure collected from the Trust (1.81%), for the period between April and December 2022, is nearly eight times higher than the government’s target rate.
Meanwhile, Bradford Hospitals NHS Foundation Trust reported a stillbirth rate of more than 5.6 per 1,000 births (0.56%) in each of the four periods investigated, whilst The Northern Care Alliance NHS Foundation Trust (covering Salford, Rochdale, Bury and Oldham) reported a rate no lower than 0.54% across the periods in question.
Differing attitudes to referral to Coroners
When a baby dies, a thorough investigation by a Coroner can provide families with much-needed answers, especially where the cause of death is unknown. Currently, however, Coroners do not have the jurisdiction to investigate stillbirths. This is because there has to have been an independent life (i.e. the baby must have lived separately to its mother) before a Coroner has jurisdiction to investigate. In spite of a government consultation on this matter launched in 2019, this state of affairs remains true today. As such, all referrals to a Coroner investigated in Tees’ report are in relation to referrals for neonatal deaths (i.e. deaths that occur within 28 days of birth).
Tees’ report also revealed large disparities in NHS Trusts’ approach to referring neonatal deaths to a Coroner, with the FOI request revealing significant inconsistencies in both theoretical understanding and practical application of Coroner referrals for neonatal deaths. Some Trusts referred all neonatal deaths to the Coroner, regardless of whether the cause of death was known or unknown, whilst others only referred cases where the cause of death was unknown.
Some Trusts have up-to-date guidance to support medical practitioners in dealing with the aftermath of neonatal deaths – however, this guidance differs between Trusts. For example, Barnsley Hospital NHS Foundation Trust states that “There is no statutory obligation to report all deaths to the Coroner, unless there is any concern that the death was unnatural.” Meanwhile, Thames Valley & Wessex states “The Coroner should be informed about any death where the cause is unknown or uncertain.”
Still other Trusts had no guidelines in place for such referrals and some did not refer any neonatal deaths to the Coroner during the periods in question, despite some having an unknown cause of death.
Uncertainty surrounding the role of HSIB (now HSSIB)
At the time the data was collected, HSIB was an independent investigator, formed in 2017, funded by the Department of Health and Social Care and hosted by NHS England. HSIB investigated cases of neonatal deaths, intrapartum stillbirths (i.e. where a baby is thought to be alive at the start of labour but is born deceased) and severe brain injury in cases referred by NHS Trusts.
Based on the paltry data gathered on this topic from some of the Trusts approached, there is poor consistency and transparency in the referral of stillbirths and neonatal deaths to HSIB. For example, neither Barts Health NHS Trust nor Dartford and Gravesham NHS Trust – Darent Valley Hospital referred all cases of intrapartum stillbirths to HSIB during 2019-20 (although this could potentially be explained by HSIB’s precise criterion for defining an intrapartum stillbirth). Still more concerning was the trust who responded to the request with “What is meant by HSIB?”
Conclusions
Despite the difficulties of producing a report based on patchy responses and incomplete data, a picture of confusion and inconsistency emerges from Tees’ investigation into stillbirths and neonatal deaths at UK NHS Trusts. The findings reveal a mixed picture across the country, with wide variations in stillbirth rates and significantly different attitudes to Coroner referrals. These remain a matter of serious concern.
Janine Collier, Head of Medical Negligence at Tees, commented:
“Whilst we recognise the pressures that maternity and neonatal services are under in terms of funding, facilities and human resources, the fact remains that the commitment made by the Health Secretary in 2015 was an important one that needs to be set and maintained on a realistic course for halving those tragic death rates by 2030.
“Key to this is close monitoring of case numbers and identification of underlying causes, so that new lessons learned in one Trust area can be swiftly applied across the country to help prevent avoidable loss of life.”
