The role of Coroners in perinatal death investigation in high-income countries: a scoping review

J Perinat Med. 2026 Jun 23. doi: 10.1515/jpm-2025-0702. Online ahead of print.

ABSTRACT

INTRODUCTION: The primary role of a Coroner is to investigate unexpected deaths. However, the global literature on Coroner’s role in perinatal death cases is limited.

CONTENT: This study used the Joanna Briggs Institute framework and comparative law methodology to evaluate existing literature from high-income countries and jurisdictions (including where relevant states or provinces). A dual-source approach reviewed peer-reviewed and grey literature across 12 electronic databases, alongside national legislation from jurisdictions with a Coronial or equivalent system.

SUMMARY: After analysing 24 countries with Coronial or equivalent systems and legislation available in English, the study found that only 12 of these countries had Coroners investigating perinatal deaths, and only one country mandated reporting of all perinatal death cases. A significant gap was found in Coroner’s role in perinatal death cases through legislative sources and peer-reviewed literature.

OUTLOOK: While global uniformity in Coronial law is not feasible, countries should adopt standardised reporting guidelines, training, and expertise to ensure consistent and high-quality death investigations. Further research is needed on holistic approaches, examining the emotional, social, and systemic factors involved in perinatal death inquiries, understanding their impacts on families, healthcare professionals, and other stakeholders, and encouraging multidisciplinary collaboration to ensure thorough and comprehensive investigations.

PMID:42329044 | DOI:10.1515/jpm-2025-0702