An anomoly in the law prevents inquiries for stillborn babies. Healthy babies die unnecessarily, with coroners powerless to investigate regardless of the level of negligence.
No independent enquiries
The coroner’s role is to inquire into deaths reported to them which may be unnatural for any reason or of unexpected and unknown cause. There is nothing natural about the death of babies.
So no deaths are prevented
The coroner has an important role in trying to prevent further deaths and, after the verdict, the coroner may announce that they will write to any person or authority that has the power to take action to prevent future deaths.