Coroner’s conundrums: born alive or still-birth, and mother’s anonymity

6 May 2017 by

R (o.t.a T)  v. HM Senior Coroner for West Yorkshire [2017] EWCA 187 (Civ), 28 April 2017 read judgment

A sad story of human frailty posed two difficult problems for the Coroner, and the Court of Appeal.

A 19-year old mother went into hospital, with a shoebox. In the shoebox was the 6-days dead body of her daughter. She told the hospital and the police that she had been raped, hence the shame about reporting the death. She had given birth in her bedroom at home, and she said that the baby had been cold when born.

But not all was as it seemed. Inquiries of the alleged rapist revealed that he and the mother had been in a secret sexual relationship. Mother eventually admitted that this was true and back-tracked on the rape allegation. Unsurprisingly, the death came before the Coroner; at very least, the cause of the death was unknown.


The first problem arose because of the pathologists’ opinion that there was no obvious cause of uterine death, or indeed of congenital disease. Such finding as there were (cerebral congestion) were consistent with but not probative of asphyxia, and any asphyxia might have been caused before or during delivery – or by suffocation.

Coroners’ duties arise in respect of the “body of a deceased person”. And neither a stillborn child nor a foetus is a “deceased person”. They never were a person.

This gave rise to the mother’s argument that the coroner had no jurisdiction to investigate this death, because he was not in a position to conclude before his formal investigations started that the child had probably been born alive.

On a literal reading of s.1 of the Coroner and Justice Act 2009, there is something in the point. But the CA concluded that, read in context, this could not be right. Because it would

require a coroner to determine as a preliminary issue on incomplete evidence one of the very matters he would be required to determine on full evidence at an inquest, namely whether the child was born alive

The Court looked at the statutory history of the role of coroners, and at editions of a leading textbook (Jervis) back as far as 1829. All contained precedents as to a conclusion that a child was stillborn, and this issue was to be considered as a preliminary issue at inquest – rather than before it.

In summary a

coroner can investigate the death of a baby who may have been born alive or may have been still-born without first being satisfied on balance of probability that it was born alive, so long as he suspects one of the matters set out in s.1(2) is in play [including unknown cause]. The question whether there was a death is a component of the matters which may be the subject of suspicion.

So the mother faces an inquest, which is why the second question arose.


The mother relied on Arts. 2, 3 and 8 ECHR in support of her contention that she should have anonymity and reporting restrictions should be imposed on the forthcoming inquest. She had been threatened by texts and on Facebook from members of her family, either to harm her or to be taken off to Pakistan to get married – so as to avoid shame on the wider family.

The CA seemed a bit sceptical about this evidence; all the texts had been got rid of, and her Facebook account deleted, and she had not gone to the police about it. I have to say none of this seems surprising to me.

However, the mother faced a major problem, in that investigation had already been opened by a previous coroner, in open court, which had been reported by the local paper, both in print and on-line. This tells the story, and identifies T as mother. This remains on-line and easily accessible.

There is of course power to order anonymity at inquest, but it requires cogent justification. The CA was not persuaded by the evidence on Arts 2 and 3 about the threats.

Art.8 required the usual balancing exercise between those rights and the rights of the press under Art.10 to report her name and the full story.

On this balancing exercise the CA was robustly against the mother

The conduct of the claimant was not in any sense a private matter….. The claimant was the central actor in what had happened. She had concealed a baby’s body for six days and failed to report the birth or still-birth. If the baby was born alive, there would be the further public interest in ascertaining the cause of death. In addition she had made a false allegation of rape against some innocent man which she only admitted after investigation by the police.

The issues were  of particular interest and importance to the local communities. There was a significant public interest in such issues being fully open for debate. Hence, the Coroner had been right to refuse anonymity and reporting restrictions.


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  1. Drachula says:

    Poor woman – it sounds like she comes from a part of society where she has little control over her choices and needs to make up stories to try to keep various sections of her family or her social sphere “happy”. Has anyone seen “killed by my father” TV drama. Whatever happened to the baby, the truth won’t be uncovered she feels to blame or there is risk of prosecution. The real perpetrators may be those who have sought to control her, and failed to allow her control over her life.

  2. ‘Born alive or still birth’?

    Immediately after birth the larynx and treachea open naturally when the
    baby cries, calling upon the Spirit, for life. The nasal cavity too will show traces of the air flow. The lungs will have air which can be doubly checked by a simple blood test which will verity the length of time the baby was alive.The quality of the air needs also to be determined as it could be another cause of taking its life.”

    Her story commenced with a lie, How can one believe the rest of her story?

    “…..This gave rise to the mother’s argument that the coroner had no jurisdiction to investigate this death, because he was not in a position to conclude before his formal investigations started that the child had probably been born alive.”

    I do not like the tone of her challenge as above.
    No bereaved mother would wish to make a firm statement being so confident of her story.

    There are many other methods of taking a life which are undectable.

    At the time of having sex for pleasure one she should have thought about the consequences of here actions. Irrelevent of the consequences, taking a life cannot be justified.Youngesters too must face the consequences of having sex for pleasure. Sex is for regeneration.

    Her family is aware and so is the ‘world’ through on Social Media as well as the press.
    There is nothing wrong in having a baby if unmarried as long as one loves that person and will be loyal to the one and not sleep around with others.

    Conclusion : Her original intent was to take its life, hence birth at home.(This sentence applies to this case alone). It is was still born, why did she not phone emergency services to seek resuscitation this would be the natural instinct of anyone wishing to save a life, particularly their own flesh and blood.

  3. Biscwuit says:

    Or perhaps her identity is not central to the purpose of the story, and doesn’t add any value in context of a report about the case. Why do you need to know who she is? What’s interests the pubic is not necessarily in the public interest.

    1. tureksite says:

      I don’t care who she is – I was just puzzled about the anonymity being continued. I expect Rosalind is right.

  4. Andrew says:

    So why is she still anonymous in the judgment?

    1. Interesting question. Normally people remain anonymous until any appeal process has expired – possibly mother had asked the CA for permission to go to the SC on the point, though it would seem a far from promising further appeal to me.

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