When Should a Baby Death be Referred to a Coroner?

When a baby tragically dies in the neonatal period, it may be appropriate - and essential - to refer the matter to the coroner. This is not about assigning blame, but ensuring transparency, accountability - and ultimately - learning.

Yet despite years of campaigning, the process remains inconsistently applied across NHS Trusts. The survival of an infant is often influenced by multiple factors during pregnancy, labour, and delivery - factors that should trigger scrutiny when outcomes are poor.

New National Scrutiny: A Turning Point

In June 2025, Health Secretary Wes Streeting launched a national investigation into NHS maternity and neonatal safety, beginning with the 10 worst-performing Trusts. A task force co-chaired by bereaved families has been appointed to guide urgent reforms, with a goal to unify standards by the end of the year.

This follows mounting evidence of persistent failures to listen to mothers, escalate concerns, and accurately report neonatal deaths. Your baby's death should never be a matter of institutional discretion.

Understanding the Role of the Coroner

The coroner’s duty is to determine:

• The medical cause of death

• The circumstances surrounding it

• Whether there were systemic or preventable factors

Referral is critical when there are concerns around hypoxic-ischaemic encephalopathy (HIE), prematurity, or clinical mismanagement - even if the immediate cause of death is known.

With the rollout of the Medical Examiner system in September 2024, every non-coronial death must now be reviewed by an independent medical examiner. This adds a new layer of scrutiny for neonatal deaths, though proper referral still depends on accurate classification and candour by Trusts.

When Referral Is (and isn't) Necessary

Referrals should be made when:

• The cause of death is unclear or potentially preventable

• There is disagreement among clinicians or with the family

• Management during labour appears substandard (e.g. CTG misinterpretation, delay in escalation)

Referrals may not be necessary when:

• There are no concerns about care

• The baby is unlikely to survive despite appropriate management (e.g. extreme prematurity or confirmed lethal anomalies)

Baby Elton Deulekom: Lessons in Accountability

In January 2022, Baby Elton was pronounced dead just 37 minutes after birth at Chelsea and Westminster Hospital. His death followed gross failings, including:

• Missed warning signs of placental abruption

• Poor CTG monitoring and lack of escalation

• Delayed delivery despite excruciating maternal pain

• No action when no foetal heartbeat was detected

Shockingly, his death was misclassified as a stillbirth, circumventing mandatory referral to the coroner. It was only after media pressure and legal challenge that the case was reopened. The Senior Coroner, Professor Fiona Wilcox, called it an “attempt at a cover-up”.

This case reflects wider systemic problems, recently highlighted again in Tommy’s and Sands 2025 progress report, which found that while stillbirth and neonatal mortality rates have improved, they remain well above national targets. The report urges urgent reform and clearer guidance on classification and referral.

A System Under Reform…But Not There Yet

In addition to the medical examiner reforms:

• A real-time neonatal death notification system (SPEN) is being rolled out in 2025. This will allow Trusts to immediately report perinatal deaths to national bodies.

• A new Maternity Outcomes Signal System is being created to track patterns and intervene early in failing services.

These initiatives are welcome, but will only work if clinicians understand and uphold their duty to refer appropriately.

Why This Matters

Misclassification of neonatal deaths undermines families’ access to justice, hides systemic problems, and stops lessons from being learned. Complaints of:

• Not listening to mothers

• Inability to interpret CTG traces

• Delays in emergency response

• Inaccurate record-keeping

…are sadly all too common in the cases we handle.

The updated Duty of Candour, combined with national maternity investigations, shows the tide is turning. But real accountability still depends on Trusts acting transparently and on families speaking up when they suspect something went wrong.

How Forbes Can Help

If you've suffered from a neonatal death or experienced serious issues during your pregnancy or labour that you believe have affected the welfare of your child, our team of solicitors is here to advise you.

At Forbes Solicitors, we understand the devastating impact that negligence can have on you and your family, which is why we’re committed to supporting you through this difficult time.

Our solicitors act with professionalism and compassion, working pragmatically to ensure you receive the medical negligence neonatal death compensation you deserve. We provide clear legal guidance, alongside the empathy and emotional support you need during what is an unimaginable and life-altering experience.

As someone who has experienced the trauma of a neonatal death, we know you’ll have many questions and need trusted answers. That’s why our expert team is here to support you every step of the way. We stand with each family seeking answers. If you need support or want to understand your options, call us in confidence on 0800 037 4625.