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Families accuse NHS of stillbirth 'cover up' denying them coroner investigations

Families accuse NHS of stillbirth 'cover up' denying them coroner investigations

Parents tell national investigation some trusts may be incentivised to record babies as stillborn rather than neonatal deaths — raising urgent questions about transparency and accountability.

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Ruairidh Pritchard

Published: February 26, 2026 at 1:51 AM

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Serious concerns have been raised that some NHS maternity units may be classifying babies as stillborn rather than recording them as neonatal deaths — potentially avoiding independent coroner investigations.

The allegation has emerged in the interim report of the Independent Investigation into Maternity and Neonatal Services, led by Baroness Valerie Amos.

Families who gave evidence told the investigation they believe the current legal framework creates a system where declaring a baby stillborn can limit scrutiny and prevent a coroner’s inquest.

Under current law in England and Wales, coroners can only investigate deaths where a baby is believed to have been born alive and then died. Stillbirths — where a baby dies before or during birth — do not automatically trigger a coroner investigation.

For some parents, that distinction has left them without answers.

“You don’t resuscitate a stillborn baby”

The investigation heard from families who described ambiguity around whether their baby showed signs of life at birth, and distress at being told their baby would be registered as stillborn.

One family member speaking to the investigation said their baby was resuscitated for 30 minutes before being declared dead, but was ultimately registered as stillborn — meaning there was no automatic coroner involvement.

You don’t resuscitate a stillborn baby. But you register a baby as stillborn, you have no investigation, an independent investigation. You’re constantly fighting because of the stillbirth registration. They’ve been able to hide behind it.

One family member speaking to the investigation

The interim report notes that several families described the system as “deeply unfair” and said the absence of a coronial investigation left them without clarity about what happened.

Some parents said they feared that recording a death as a stillbirth prevented external scrutiny.

Incentives and unanswered questions

Baroness Amos stops short of concluding that trusts are deliberately misclassifying deaths. However, she acknowledges concerns raised by families that the current framework may create perverse incentives.

The report states that some families felt the system “incentivised the recording of deaths as stillbirths” because this prevents the case from being investigated by a coroner.

It also highlights cases where there was ambiguity about whether a baby was born alive, creating long-lasting trauma for parents who said they were left in limbo.

The investigation has expanded its review beyond previous government consultations — which focused only on stillbirths from 37 weeks gestation — to examine whether coronial involvement should apply more widely from 24 weeks onwards.

A legal gap under scrutiny

The Coroners and Justice Act 2009 currently limits coronial investigations to cases where there is reason to suspect a baby was born alive and then died.

Families told the investigation that this threshold can be difficult to challenge, particularly when medical staff determine signs of life.

Some said they felt pressured to accept stillbirth registration in order to arrange a funeral or receive official documentation.

One parent described being told that if they did not register their baby as stillborn, they “wouldn’t be able to have a funeral”.

Calls for reform

Campaigners have long argued that extending coroners’ powers to investigate stillbirths would improve transparency and learning.

Several high-profile maternity inquiries in recent years — including East Kent and Shrewsbury and Telford — uncovered systemic failures that went unchallenged for years.

Baroness Amos writes that when families do not receive full explanations, the trauma is compounded and trust in the system erodes.

While some families who went through the coronial process after neonatal deaths described it as adversarial, others said it provided clarity and accountability they would not otherwise have received.

The investigation will now examine whether changes to the law are needed to ensure consistent independent scrutiny when babies die before or during birth.

Wider maternity crisis

The stillbirth classification concerns sit within a broader finding that the maternity system is “not working for women, babies and families, or for staff.”

The interim report identifies systemic issues including:

Poor responses and lack of accountability when harm occurs
Resistance from trusts when families request medical notes
Instances of notes being amended or redacted
Persistent racial disparities in outcomes
Staffing shortages and leadership failures

Final recommendations are expected later this year. The Health Secretary has said a national taskforce will draw up an action plan in response.

For families who believe their baby’s death was recorded in a way that limited scrutiny, the hope is that this investigation may finally bring reform.

Whether it results in changes to coronial law, and greater independent oversight of stillbirths, will now be closely watched.

Authors

Ruairidh PritchardDigital Growth Lead

Ruairidh is the Digital Lead on MadeForMums. He works with a team of fantastically talented content creators and subject-matter experts on MadeForMums.