Abstract

This scoping review explores how coroners and equivalent officials investigate perinatal deaths in high‑income countries, and how their roles are defined in law and practice.

Perinatal deaths are typically investigated by judicial or medico‑legal officers such as coroners, medical examiners, or officials like the Procurator Fiscal in Scotland, but the scope of their involvement varies widely between jurisdictions. Using Joanna Briggs Institute scoping review methods and a comparative law approach, the authors searched national legislation in 83 high‑income countries and 12 academic and legal databases to identify how coroners’ roles in perinatal death investigation are structured. They found 24 countries with a coronial or equivalent system and English‑language legislation; of these, only 12 explicitly list perinatal deaths as reportable, and Ireland is unique in mandating that all perinatal deaths must be reported to the Coroner.

From 1,454 records screened, 24 documents (2000–2024) were included, mainly from the UK, Ireland, Australia, New Zealand and the US. The review shows substantial variation in titles, required expertise, and triggers for coronial involvement, with often unclear guidance on when an inquest is needed for non‑suspicious hospital perinatal deaths. This regulatory diversity can create ambiguity for clinicians and families, and influences how perinatal deaths are reviewed and learned from. The authors highlight the need for clearer, more consistent coronial frameworks around perinatal deaths to support transparent investigation, family confidence, and system‑level learning.