Coroners’ advice on maternal deaths in England and Wales routinely ignored, study finds | NHS
Advice given by coroners in England and Wales to help prevent maternal deaths is not being followed, research suggests.
Academics from King’s College London examined Prevention of Future Death (PFD) reports issued by coroners in cases of pregnant women and new mothers who died between 2013 and 2023. They found that these reports were not “systematically used nationally”.
The study, published in BMJ Gynecology and Obstetrics Clinical Medicine, identified 29 PFDs involving maternal deaths, but found that almost two-thirds of these reports were ignored.
Two-thirds of deaths occurred in hospitals, and more than half of women died after giving birth. The most common causes of death were hemorrhage, early pregnancy complications and suicide.
Concerns raised by coroners most often related to the failure to provide appropriate treatment or to escalate cases, as well as lack of training.
NHS organisations, like other professional bodies, are legally required to respond to the coroner within 56 days, but the study found that only 38% of PFDs had published the responses from the organizations they were sent to.
According to the latest figures from the World Health Organization, around 260,000 women died during and after pregnancy and childbirth, although most of these cases could have been avoided. While the vast majority of maternal deaths occur in low- and middle-income countries, the risk of maternal mortality in wealthier countries averages 10 per 100,000 live births.
In England, the maternal mortality rate for 2021/23 was 12.82 per 100,000 births. In June, Health Secretary Wes Streeting announced an investigation into NHS maternity services in England after a series of failings in the health system.
Dr Georgia Richards, a researcher at King’s School of Life Sciences and Medicine and lead author of the study, said the findings should be used to address failures and accelerate efforts to prevent similar deaths.
“The voices of mothers and pregnant people must be taken seriously. Until then, PFDs should be included in the next independent inquiry into NHS maternity and newborn care led by Baroness Amos to ensure the same failures and deaths do not happen again.”
Richard Baish, head of development at Action on Postpartum Psychosis, whose wife Alex took her own life in 2022 after the birth of their daughter Rosie, said: “Baby blues is used as a throwaway term, but postpartum psychosis can be life-threatening if not treated quickly and appropriately.
“There were no warning signs for Alex, which is why it was so tragic that her GP didn’t listen to her. Alex was behaving strangely and was the siren for help. If lessons are not learned, it is likely that other women like Alex will slip through the cracks.”
A spokesperson for the National Maternity and Newborn Inquiry said: “The aim of the independent inquiry is to identify systemic problems that have led to poor outcomes, including deaths, in maternity and newborn care across England.
“The lived experiences of women, babies and families are absolutely at the heart of this. The inquiry will look at relevant prevention of future death reports.”
A Department of Health and Social Care spokesperson said it was “unacceptable” that organizations were not responding quickly to PFDs.
“Too many families have been devastated by serious failures in NHS maternity and newborn care,” they said. “That’s why we have commissioned an urgent independent national inquiry and are setting up a taskforce, chaired by the Secretary of State, to root out systemic failings and implement a plan for real change in maternity and newborn care across the country.
“We are also taking immediate steps to improve the safety of maternity and newborn care, including through advanced monitoring systems and programs aimed at preventing brain injury during childbirth. »
