Disturbing new research has exposed that vital recommendations from coroners designed to prevent pregnant women and new mothers from dying are being systematically ignored by healthcare providers across England and Wales.
Systemic Failures in Maternity Care
The comprehensive study conducted by experts at King's College London examined Prevention of Future Deaths (PFD) reports issued by coroners between 2013 and 2023. Researchers discovered that critical gaps in care identified by medical professionals are not being "systematically used nationally" to avoid repeating tragedies.
Among the 29 maternal death cases analysed, most occurred in hospital settings, with more than half of the women dying after giving birth. The research reveals a troubling pattern of healthcare failures that continue to claim lives despite clear warnings from coroners.
Causes of Death and Critical Concerns
The data reveals haemorrhage as the most common cause of maternal death, accounting for 27% of cases. Equally alarming is that one in five women took their own life, while 20% died during early pregnancy from complications including terminations or ectopic pregnancies.
Coroners repeatedly expressed concerns about fundamental care failures, with 48.2% of reports highlighting inadequate treatment and 37.9% citing failures in timely escalation of care. Nearly a third (31%) of reports identified insufficient staff training as a critical issue.
Perhaps most concerning is the lack of accountability revealed by the research. Only 38% of PFD reports received published responses from the organisations they were sent to, though 80% of those who did respond claimed to have implemented changes.
Personal Tragedy Highlights Systemic Failure
The human cost of these failures is devastatingly illustrated by the story of Richard Baish, whose wife Alex took her own life in October 2022 after giving birth to their daughter Rosie.
"Alex had no mental health issues when we had our first child," Mr Baish explained. "A month after Rosie was born, Alex had a sudden downturn in her mental health. She had no previous history, a strong family network and no red flags."
Despite visiting her GP and being prescribed antidepressants, Alex was sent home rather than to hospital for assessment. She died by suicide that same evening on October 24, 2022.
Mr Baish emphasised that "postpartum psychosis can be life-threatening if not dealt with swiftly and appropriately" and warned that without learning lessons, other women will continue to "slip through the net."
Call for National Action
Dr Georgia Richards, research fellow at KCL, stressed that "every maternal death is a tragedy, a failure to the mother, their family and their child." She advocates for tracking PFDs to identify repeated concerns and gaps where organisations must act to save lives.
The current maternal death rate in England stands at 12.82 per 100,000 women giving birth for 2021-2023. Dr Richards has called for PFDs to be included in the upcoming maternity review led by Baroness Amos.
The Department of Health and Social Care acknowledged the seriousness of the situation, stating that "it is unacceptable for organisations not to respond promptly" to PFD reports. They highlighted ongoing efforts including an urgent national independent investigation and taskforce to address systemic failures in maternity and neonatal care.
