Family still waiting for inquest, death certificate four years after baby's death

Kianty and Conor Simpson are still waiting for the basic paperwork that should have followed their son’s death four years ago. Jacob Simpson was just four days old when he died after what his parents describe as multiple failings during his birth at Glangwili Hospital in Carmarthen, and they say the absence of an inquest has left them unable to move forward with the most basic rites of grief.

Jacob suffered a lack of oxygen to his brain during his birth in June 2022, before his life support machine was turned off days later at Singleton Hospital in Swansea. It was the first time Kianty and Conor were able to hold him. Even now, the couple still do not have his death certificate, and they have not scattered his ashes because no inquest has been held. For a family already living with the loss of a newborn son, the delay has extended the trauma into daily administration, denial and uncertainty.

The Simpsons were living in Haverfordwest, Pembrokeshire, when Conor was posted to west Wales with the Army and Kianty fell pregnant. On 15 June 2022, Kianty was taken to Glangwili Hospital to be induced, but labour began spontaneously. Conor said he knew something was wrong as soon as Jacob was born because he was pale and bluish, and he recalled watching him be resuscitated for 22 minutes. The family says those moments have never been properly explained to them, and the long wait for an inquest has left them without answers, without closure and unable to complete the rituals that help many bereaved parents begin to grieve.

The coroner for Carmarthenshire and Pembrokeshire has apologised for the delay and said Jacob’s case was now a priority. Under coroner procedures in England and Wales, deaths that are violent, unnatural, sudden or of unknown cause are investigated to establish how the person died before the body is released for cremation or burial. Delays in that process can also hold up registration of the death. Official guidance says the paperwork can differ when a death is reported to a coroner, and families may have to wait until examinations are finished before registration can proceed.

A multi-year delay is far beyond the norm. Office for National Statistics data show the median registration delay for deaths certified by coroners in England and Wales was 26 days in 2022. The Simpson family’s experience has unfolded against wider concern about maternity and neonatal safety in the NHS, with the government’s recent national maternity investigation intended to provide truth to families harmed and improve care and safety. For Kianty and Conor Simpson, though, the process that should have clarified how Jacob died still has not delivered the most basic answers.