Despite advances in perinatal care, a few babies die unexpectedly at or soon after birth. The most likely cause is perinatal hypoxia. Sometimes the reason for this hypoxia is clear (such as antepartum haemorrhage or obstructed labour). In other instances there may be no explanation for the event and questions may be raised whether the death could have been prevented. Although it is the norm for all centres to discuss all perinatal deaths in mortality and morbidity meetings, more recently, anecdotally it seemed that many units have been choosing to refer such cases to the coroner. These referrals can be stressful for the obstetric and paediatric teams as they may lead to a coroner’s …