Reporting a perinatal death to the Procurator Fiscal (1010)

The death of any baby who falls into the following categories should be reported to the Procurator Fiscal:

• a sudden, unexpected and unexplained perinatal death including deaths where results of investigations which may explain the death are outstanding

• where the body of a newborn is found

• where the death may be categorised as a Sudden Unexpected Death in Infancy (SUDI)

• which arises following a concealed pregnancy

• stillbirths / neonatal deaths following maternal trauma / assault / domestic abuse

• unexplained neonatal death including deaths due to hypoxic ischaemic encephalopathy where the cause for this is unknown
• neonatal death with unexplained collapse / poor condition at birth

Many intrauterine deaths will be unexplained at the time of birth.  If the obstetric team are in any doubt about whether to submit a report (even if investigations are in progress), it is advisable to discuss the death with the Procurator Fiscal in advance of submitting the report as it will depend on the individual circumstances in each case.

Factors which make a stillbirth reportable will include, but are not limited to, the following:

• where concerns have been expressed

• the circumstances will be likely to be subject to an Adverse Event Review

• it is an unexpected or unexplained intrapartum stillbirth

All reportable deaths must be notified to the Procurator Fiscal as soon as possible after occurrence and before any steps are taken to issue a death certificate.

In situations where it is not clear if the perinatal death is reportable, discussion with the Procurator Fiscal should take place as soon after birth as possible.

The need to contact the Procurator Fiscal must be considered before a Post Mortem is discussed with the parents, especially if consent for a PM is not going to be given.

If the obstetric team are unsure what to do in a particular case, Dr Penman (Consultant Paediatric and Perinatal Pathologist) can be contacted for advice via switchboard (out of hours on-call service also provided).

The doctor with the most detailed knowledge of the circumstances of the death should report it.  For a perinatal death, the on-call Obstetric Consultant should be involved in determining who is to do this.

The death can only be reported by a medical practitioner – the doctor may need to discuss the death with the midwife in advance of reporting it to ensure he/ she has a detailed knowledge of the death and is in a position to provide all relevant information and answer any questions that may be asked about the circumstances of death.

The death should be reported to the Scottish Fatalities Investigation Unit (SFIU) team in whose area the significant event leading to the death occurred.

For perinatal deaths which have occurred in NHS Greater Glasgow and Clyde, contact details for the SFIU West team which is based in the Procurator Fiscal’s office in Glasgow are:

SFIU WEST
Telephone: 0300 020 1798
Email: SFIUWest@copfs.gov.uk

In normal circumstances, death reports should be made to the Procurator Fiscal during office hours.  In situations where the death is suspicious, a death report may be made outside office hours to the on-call service, contactable through the police.  This facility should be used in exceptional circumstances only where the matter cannot wait until the next working day.

The reporting doctor should provide the Procurator Fiscal with all of the information required by completing the ‘Notification of Death’ form (ef5 form), a copy of which is contained in Annex 3 of the COPFS guidance (via above link).

An advance call for advice is not a substitute for submitting a completed ef5 if the outcome of the advice call is that the death is reportable to the Procurator Fiscal.

The blank eF5 form will be emailed to you if you do not have access to a copy and should be returned by email to the SFIU West mailbox as soon as possible.

It may be necessary to have a further discussion with the Procurator Fiscal after the eF5 has been received.

The reporting of the death and all discussions with the Procurator Fiscal should be recorded in the mother’s BadgerNet record.