When should a neonatal death be referred to the coroner? Initiation of a guideline to aid decision making

Despite improved survival, particularly for extremely preterm infants, sadly some neonates die. When this happens, it may be appropriate to refer the death to the coroner, however, there is huge variation in practice between settings regarding the coroner referral process. After a particular case concerning several hospitals, we reviewed available evidence and produced a guideline to aid this process, involving both neonatologists and our coroner’s office, and including parental concerns. This has enabled a systematic, transparent approach that is equal for all infants.

Narendra Aladangady
FRCPCH, PhD
Consultant Neonatologist and Honorary Clinical Professor in Child Health, Neonatal Unit, Homerton University Hospital NHS Foundation Trust, London, and Queen Mary University of London
n.aladangady@nhs.net

Philippa Chisholm
FRCPCH
Consultant Neonatologist, Neonatal Unit, Homerton University Hospital NHS Foundation Trust, London