NHS logging baby deaths as stillbirths ‘to avoid scrutiny’

NHS hospitals have claimed that babies born alive were stillborn, a Telegraph Investigation has found, prompting accusations they were trying to avoid scrutiny.

Six children who died before they left hospital were wrongly described as stillborn. Several of the children lived for minutes and one lived for five days.

Coroners are not able to carry out inquests into stillbirths, leaving some families unable to get answers until the error was corrected. In one case, an obstetrician told a coroner in Stockport that he had been pressured by an NHS manager to say a baby he had delivered had definitely been stillborn, in order to be “loyal” to the trust. 

His comments are likely to raise fears that some NHS trusts in England have used the stillbirth label to avoid having coroners examine any errors that may have been made by staff. 

Although coroners are legally allowed to hold a narrow, preliminary investigation into whether the baby was born alive or not, they must halt the case if they find the child is stillborn – meaning they cannot examine what went wrong. Families of babies wrongly labelled stillborn also face financial implications, because they are not automatically eligible for statutory “bereavement awards” worth more than £15,000. 

The revelations raise questions over transparency at some NHS trusts, and come ahead of what is expected to be a “harrowing” report into failings in the maternity unit in East Kent Hospitals University NHS Foundation Trust, stretching back more than 10 years. Dr Bill Kirkup, who is leading the review, has previously warned trusts to avoid “fending off” inquests. 

The babies identified by The Telegraph should have been recorded as neonatal deaths, but staff claimed they were stillbirths – babies that never had any signs of life outside the mother’s body, even for a single moment. 

All the NHS trusts that wrongly classified neonatal deaths as stillbirths have apologised to the babies’ parents, and say they have changed their practices. 

Stockport Trust denied trying to avoid scrutiny, and said it carried out an immediate internal investigation. East Kent Trust said that since 2018, decisions on all referrals to the coroner have also been made by the medical examiner.

‘Our baby was alive for five days but was recorded as a stillbirth’

It was a warm November day in 2016 when Kelli Rudolph went into labour, and she was excited to finally meet her new daughter. 

“There were roses blooming in the garden. I went for a walk outside. It was good,” the academic says. But as soon as her waters broke, Dr Rudolph saw “really thick meconium” – the name given to a baby’s sticky first stool, which can pose a serious danger to an unborn child. 

She was rushed to hospital in an ambulance, expecting that she would have an emergency caesarean on arrival, but she was instead taken to a labour ward where staff struggled to get her baby, Celandine, out fast enough. 

In the end, Celandine suffered hypoxic ischaemic encephalopathy (HIE) – brain damage from a lack of oxygen – and needed to be resuscitated at birth. However, she survived and lived for five days with her parents in hospital. 

Celandine’s father, academic Dr Dunstan Lowe, says he initially believed that her death “had been a horrible freak accident”.  

But as events unfolded, he and his wife started to wonder if there was a pattern of failures at East Kent Hospitals University NHS Foundation Trust, and began to question the trust’s openness. 

Before the couple left hospital, staff handed them Celandine’s death certificate, citing HIE as one of the causes of death, and “stillbirth” as another. 

When the couple later registered Celandine’s short life and death, Dr Rudolph says the registrar was “just shocked”. However, at the time, the doctor had told them that Celandine’s condition at birth meant “really, she was dead”. 

Staff also discouraged them from having an inquest, on the basis that the cause of death was already known. In fact, they may have struggled to get one. Coroners have legal powers to investigate the deaths of babies that have lived for even one second but, unless the law is changed, they cannot open an inquest into a child that was stillborn. 

No inquest that could provide answers

The trust has now admitted that it was wrong to log Celandine’s death in the way it did but “stillbirth” is still on her death certificate and there has never been an inquest to provide her parents with answers. Looking back, Dr Lowe believes staff did not want events examined. 

“The reason they used this word on the death certificate seems quite obvious to us – it’s about avoiding scrutiny,” he said.

Dr Rebecca Martin, chief medical officer for the trust, said it was sorry for Celandine’s loss and “apologises unreservedly”. The trust added that, since 2018, all babies who have died in hospital from HIE are referred to the coroner automatically.

But while this might offer some reassurance, the Telegraph has identified five other cases, at NHS trusts across the country, where families have been told that babies born alive were in fact stillborn – raising further concerns about transparency. 

The disclosure is likely to fuel the concerns raised by Dr Bill Kirkup in his review of maternity services in Morecambe Bay. He said the “illogical” ban on inquests for stillbirths offered a  “subtle incentive for staff to record a death as a stillbirth” if there was any controversy over the delivery. 

Obstetrician claims he was put under pressure

Elsewhere, Dr Mark Tattersall, a locum obstetrician at Stockport’s Stepping Hill Hospital, claimed in a coroner’s court in 2020 that an NHS manager put pressure on him to say that one of the babies he had delivered – a child called Evelyn Davies – had been stillborn, even though notes from the time suggest she may have been alive and that there was at the very least confusion. 

In his witness statement, he said the manager said “all the other statements provided by other staff made it clear the baby had been stillborn” and “suggested that I should have ‘loyalty to the trust’”.

“I felt that I was being put under pressure,” he said. The NHS manager denied that in court, and, in any case, Dr Tattersall did nothing of the sort. That’s because his own recollection of events suggested Evelyn was most probably alive when she was born. He delivered her by C-section at 26 weeks, and “specifically” remembers a medic saying Evelyn was alive while Dr Tattersall finished operating on her mother, Liz Davies.

The midwife’s notes at the time say “?showing some signs of life [sic]”, although she added a retrospective note saying she made a “judgment error”. 

Evelyn’s father, Major Matthew Davies, a decorated Army veteran, was in a nearby room waiting on news of his wife and daughter. Evelyn was very premature and he says he was relieved when a midwife told him she was “perfect” but needed some help to breathe. Around 10 minutes later, a doctor told him she wanted to stop trying to resuscitate his daughter. He was devastated. 

Major Davies took it upon himself to break the news to his wife when she woke. However, their grief turned to shock two days later when another midwife informed them that actually, Evelyn had never lived. 

Major Davies recalls: “She said, ‘What have you been told … she was never alive.’ It was only at that point where we thought, ‘What the hell is going on here?’” and, as events unfolded, they started to wonder if failures at East Kent Hospitals University NHS Foundation Trust were a one-off, and questioned its openness. 

“I find it more likely than not that she probably did live, albeit only momentarily in the arms of [the] midwife,” the coroner said. The couple were still shocked when they heard Dr Tattersall’s claim that he was put under pressure by a manager.

Apology for  'miscommunication'

Stockport NHS Foundation Trust has apologised to Major Davies and Mrs Davies for “miscommunication” and the distress it caused, and strongly denies any suggestion that it misclassified  Evelyn’s death knowingly. 

“We carried out an immediate investigation – as is our usual process for all stillbirths and neonatal deaths – and we also contacted the coroner who concluded that Evelyn died from natural causes,” it said. It also reports all stillbirths and neonatal or perinatal deaths to an arm’s-length body. 

Major Davies feels the trust tried to write off his daughter’s life in order to avoid having to examine her death. He thinks it’s “not because they understood what had gone on and they wanted to cover it up necessarily. They just didn’t want to investigate ... because it’s just too much of an embuggerance. It looks bad in their statistics.” 

The other babies wrongly categorised as stillborn were: Clara Tully, who died in 2014 after midwives at Warrington Hospital wrongly sent her mother home in labour; Ava Mae Charlton, who died after 32 minutes at Milton Keynes Hospital in 2009; and Rueben Winrow Monks, born under the care of Wrightington, Wigan and Leigh Trust in 2011.