Page last updated at 04:02 GMT, Tuesday, 1 June 2010 05:02 UK

Shipman coroner says all baby deaths must be probed

By Ann Alexander
BBC File on 4

John Pollard (courtesy of the Manchester Evening News)
John Pollard asks that all baby deaths in his area should be reported to him

The way in which neonatal deaths are investigated should be more consistent, a senior coroner said.

John Pollard told the BBC the deaths of all babies in hospital should be reported to the local coroner or, in Scotland, to the procurator fiscal.

Currently, baby deaths in hospitals are only reported if they are sudden, unnatural or violent.

The Coroners Society said it could not direct its members to follow a particular practice.

In the UK, on average 17 babies die every day - either at birth or in the first four weeks of life.

Hospital investigation

"The law says that the death of babies is of course treated in the same way as the death of anyone else and therefore if it is that the doctors can certify the death as being natural there is no reason why the death should be brought within the ambit of the coroner," Mr Pollard told BBC File on 4.

Rachel and Chris Spencer's baby, Rose, was stillborn

But he added: "My own view, however, is that it would be helpful if the death of all children, particularly very young children and babies, could be reported to the coroner so that we had a consistent overview of what was happening."

Mr Pollard, who is coroner for Stockport and South Manchester and held the inquests into the victims of Harold Shipman, has asked that he is notified of all deaths of babies and young children in his area.

When he is informed of a death his officers carry out an investigation at the hospital concerned. They interview the family and staff and gather evidence.

Mr Pollard said only a minority of coroners are carrying out a similar policy principally because there is no legal basis to force the doctors to report these deaths.

'Deaths missed'

He said unnatural deaths may be missed in areas where the coroner has not been informed.

"One of the main drivers for me is to prevent future deaths occurring in similar circumstances. If we can learn from what has happened then I think we can prevent further deaths."

"Sadly the corollary in other jurisdictions where they are not doing this is there could be a repetition of the type of deaths we are talking about."

The Coroners Society, which represents all coroners in England and Wales, said in a statement said that it is up to each individual coroner to decide how to interpret the law on a case-by-case basis. It said it was not within its authority to direct coroners to follow a particular practice.

Some parents however, claim they have to fight to get a satisfactory explanation to find out about their baby's death.

Rachel and Chris Spencer's baby, Rose, was still born due to a placental abruption last October. The Spencer's grief has been compounded by the battle they have had to find out what happened on the night Rose died. Rachel had reported an unusual pain whilst in early labour, but the medical team said she was fine and told her to go home. They told BBC producer Jennifer Clarke what happened when they returned to the hospital a few hours later.

Stoke Mandeville hospital have apologised to the Spencers for the standard of care they received. They say they have a well established method of case review and insist nothing they could have done would have changed the outcome for Rachel's baby.

File on 4 is broadcast on BBC Radio 4 on Tuesday, 1 June, 2010, at 2000 BST, repeated Sunday, 6 June, at 1700 BST. You can listen via the BBC iPlayer or download the podcast.

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