Lengthy delays in coronial post-mortem reports for perinatal deaths

A leading obstetrician has raised concerns about the long waiting times faced by many families for receipt of coronial post-mortem reports into perinatal deaths.

Prof Keelin O’Donoghue, Consultant Obstetrician, Cork University Maternity Hospital, said an increasing number of perinatal deaths and stillbirths are subject to coronial investigation.

The Coroners (Amendment) Act 2019 increased and clarified the range of reportable deaths, including infant deaths.

“The decision to dictate that all perinatal deaths were reportable to the coroner was likely intended to ensure that parents who had a stillbirth or neonatal death had access to an independent review of their case,” Prof O’Donoghue commented. “It is clear that in some circumstances coronial involvement is entirely appropriate, but the Act has had unintended consequences by including every baby death.”

Prof O’Donoghue stated that coroners differ in their approach to these deaths with some directing that the majority have coronial post-mortems.

“Normal communication pathways between pathologists and their obstetric or neonatal colleagues are also changed in these scenarios as the pathologist can only convey their findings to the coroner unless specific authorisation is obtained,” she added.

She said the legalistic nature of the investigation may influence the type of post-mortem report produced and impact on communications between the relevant parties.

“It is only when all information is released that parents can discuss the post-mortem findings with their clinician, discuss what happened and make a plan for the future,” said Prof O’Donoghue, who noted that individuals may wish to have another pregnancy in the near future and be informed of potential recurrence risks.

It can take at least two years for families to receive the post-mortem report, although the timeline can vary. “For many perinatal deaths I do not see how this process works well for anyone involved,” she said.

Meanwhile, Prof O’Donoghue noted progress in addressing difficulties recruiting into perinatal pathology services. “This [work] has included actively looking for interested trainees and building teams that they might want to join, as well as initiatives in training scientists.”

Plans to reform the coroner service are due to be published in the coming months. The plans are being costed and a Heads of Bill will be brought to Government this year, according to the Department of Justice.