11 Jun 2014

The parents waiting two years to find out why their babies died

A Channel 4 News investigation has found that parents whose babies die at birth, or shortly after, are in some cases being denied inquests to find out what happened.

Any death where something appears to have gone unexpectedly wrong during the labour or delivery and where the baby would have been expected to live is meant to be reported by the hospital to the coroner.

And any death described as ‘unnatural’ is meant to be investigated by the coroner who will decide if an inquest needs to be he held.

But this is not always happening.  Our research shows that hospitals are not reporting deaths when they should and coroners are not investigating when they would be expected to.


There is also evidence that some hospitals are mislabelling neo-natal deaths as stillbirths because these do not, by law, have to be looked at by a coroner.

And despite the Chief Coroner and the Ministry of Justice ordering coroners to speed up the length of time it is taking to complete inquests, we have spoken to a number of parents who have waited more than two years to find out why their babies died.


Presented with our evidence, the Justice Minister Simon Hughes has now said he will hold a meeting with health officials and the chief coroner to discuss the issues raised.

Mr Hughes has also said he will meet with the bereaved families, whose cases we brought to his attention.

Solicitor Sarah Harman, who is representing some of the families, said that she had begin to notice a troubling pattern emerging.

“More and more times  I am instructed by a bereaved family and my first question is whether there is going to be an inquest and they haven’t even heard of an inquest,” Ms Harman said.

“So then I report the death to the coroner and very often the coroner will immediately say there should be an inquest.  The question I have to ask is why hasn’t the hospital followed its own procedures and why haven’t they followed the law?”

Chanell Miller gave birth to a twin boy and girl early at 28 weeks at Newham Hospital in East London in May 2012.  But her baby girl Ka’Leah died at just nine days old.  Her son, Kaleem survived.

A postmortem later revealed that a long line, inserted into Ka’Leah to help her feed, had pierced her heart cavity.

Inquest ordered

Yet the death was not reported to the coroner and it was only when Ms Harman became involved that an inquest was ordered.

Ms Miller, who has five boys, said the inquest could not bring back her daughter but it could provide answers and prevent something similar happening again.

“She was my only daughter,” she said.  “I could never get her back so the most I can do is at least try and fight for her.  I can’t buy her pretty dresses or do her hair so what I have to do is to try and fight for her name and try and save other babies.”

Archna and Shilane Patel are still, though, fighting for an inquest for their son Rohan.  He died 24 hours after he was born, his parents having to make the heart rending decision to switch off his life support and, as they said, let him go in peace.

The medical notes reveal a catalogue of missed opportunities before and during the birth.  Yet the hospital did not report the death and when the parents approached the coroner, he refused an inquest.

They have now commissioned their own expert medical report which supports the need for an inquest and they are now planning to submit that.

“I just want to know whether or not it could have been averted and I think that is partly the purpose of an inquest,” Mrs Patel said.

Ms Harman said that she was finding coroners were setting the bar too high and saying baby deaths are natural.  “Even when the circumstances leading to the deaths might be very questionable indeed,” she said.

‘Unsafe practices’

Although sympathetic to the enormous workload coroners are facing, Ms Harman said it mattered that the system worked.  “If the coroner won’t investigate deaths that should be investigated and if hospitals don’t report deaths that they should, then it follows that we are going to have unsafe practices in hospitals that will continue to the detriment of us all.”

Holding an inquest can, however, result in some hard questions being asked of hospitals.  And we have evidence that to avoid this some hospitals are labelling deaths as stillbirths so there will not be an inquest.

A letter from one coroner which has been passed to Channel 4 News reveals that he has become so concerned he has asked all stillbirths to be referred to him.

The letter said:  “If there is evidence that the baby had a heart beat or was breathing then I consider whether or not an inquest should be held.

“The procedure is not always popular but I believe it is necessary to ensure that hospitals do not seek to avoid the coroner by classifying the death as stillbirth.”

But even when parents do manage to secure an inquest, it can take years.  Following the Government request to speed up the process the average time to completion is now 28 weeks.

But we spoke to one mother who was still waiting two-and-a-half years after the death of her son.

Joanne Noad’s baby Reece became stuck in her pelvis during the birth, a condition called shoulder dystocia.   Ms Noad had previously had this problem with her second child and it was in her notes.

‘You should have known’

“One of the midwives did say to me she was really sorry and that if they had known I had previously had these problems they would have done things differently,”Ms Noad said.

“I remember saying to her ‘well, you should have known.  It was in my notes.”

Ms Noad is now pregnant again and is increasingly anxious that the inquest is held so she can have some answers before she gives birth again.

But it was not until we contacted the coroner to ask why she was still waiting that Ms Noad was given a date.  Indeed, just over two hours after we wrote to the coroner, she received an abject apology and a few days later she was give a date in August.

The inquest into the death of Chanell Miller’s daughter Ka’Leah is also expected to be heard this week – two years after her death.

Bart’s Health NHS Trust, which is now responsible for Newham, said in a statement to Channel 4 News that it was extremely sorry for the distress caused.  They added that the clinicians involved in Ka’Leah’s care were in early contact with the coroner and had co-operated at every stage with the inquest proceedings.

They said that they had made changes and improved staff training for the insertion of the lines used to help feeding.

But the fact is that the only reason the inquest is being held at all is because Ms Miller and her family and their solicitor fought for it.  The system did not work as it should have done and there is clear evidence that they are not the only family who have had to fight to find out the answers they desperately need.

UPDATE: And some two years after the death of Chanell Miller’s daughter Ka’Leah, the inquest finally took place on 11 July.  The coroner recorded a narrative verdict, saying her death was due to the incorrect insertion of the long line to help her feed and the failure of senior doctor to review it.

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