Coroners' Warnings on Maternal Deaths Routinely Overlooked
Shocking new research reveals that vital advice from coroners designed to prevent the deaths of pregnant women and new mothers in England and Wales is being systematically ignored. A comprehensive study from King's College London has found that nearly two-thirds of official warnings issued after maternal deaths have not been acted upon, raising serious concerns about patient safety within NHS maternity services.
Systemic Failures in Maternal Care
Academics examined Prevention of Future Deaths (PFD) reports issued by coroners between 2013 and 2023 involving maternal fatalities. Their findings, published in the BMJ Gynecology and Obstetrics Clinical Medicine journal, identified 29 such reports specifically concerning maternal deaths. Alarmingly, the research team discovered that these crucial documents are not being "systematically used nationally" to improve care standards.
The statistics paint a troubling picture: two-thirds of these maternal deaths occurred in hospitals, with more than half of the women dying after giving birth. The most frequent causes of death identified were haemorrhage, complications during early pregnancy, and suicide. Coroners most commonly raised concerns about failures to provide appropriate treatment, inadequate escalation of critical cases, and insufficient staff training.
Legal Requirements Being Disregarded
Under current regulations, NHS organisations and other professional bodies are legally required to respond to coroners' PFD reports within 56 days. However, the King's College investigation found that only 38% of these reports had published responses from the organisations to which they were sent, indicating widespread non-compliance with statutory obligations.
Dr Georgia Richards, research fellow at King's faculty of life sciences and medicine and lead author of the study, emphasised the urgent need for change. "The voices of mothers and pregnant people must be taken seriously," she stated. "Until then, PFDs should be included as part of the upcoming independent investigation into NHS maternity and neonatal care by Baroness Amos to ensure that the same failures and deaths do not occur again."
The global context underscores the seriousness of the situation. World Health Organization figures indicate that approximately 260,000 women died during and after pregnancy and childbirth worldwide, with most cases considered preventable. While wealthier nations generally have lower maternal mortality rates, England's rate for 2021/23 stood at 12.82 per 100,000 births.
Personal testimony highlights the human cost of these systemic failures. Richard Baish, development manager at Action on Postpartum Psychosis, lost his wife Alex to suicide in 2022 after the birth of their daughter Rosie. "Baby blues is used as a throwaway term, but postpartum psychosis can be life-threatening if not dealt with swiftly and appropriately," he explained. "There were no red flags for Alex, which is why it was so tragic her GP didn't listen to her. If lessons aren't being learned then it's likely other women like Alex are slipping through the net."
In response to these concerning findings, a Department of Health and Social Care spokesperson described organisations failing to respond promptly to PFDs as "unacceptable". The department confirmed that Health Secretary Wes Streeting has announced both an urgent national independent investigation and a taskforce to address systemic failures in maternity and neonatal care across England.
A spokesperson from the national maternity and neonatal investigation added: "The aim of the independent investigation is to identify the systemic issues that have led to poor outcomes, including deaths, in maternity and neonatal care across England. The lived experiences of women, babies and families are absolutely at the heart of this. The investigation will review relevant prevention of future death reports."
