Preventable deaths: Urgent Action Needed as Coroners’ Warnings on Maternal Care Ignored
A new study reveals a disturbing trend: critical advice issued by coroners in England and Wales to prevent future maternal deaths is frequently being overlooked, potentially endangering the lives of new and expectant mothers. The research, conducted by academics at King’s College London, highlights a systemic failure to act on prevention of future deaths (PFD) reports issued following maternal mortality cases between 2013 and 2023.
The study, published in the BMJ Gynecology and Obstetrics Clinical Medicine, identified 29 PFDs related to maternal deaths, but found that nearly two-thirds of these crucial reports were effectively ignored by responsible organizations. This lack of response raises serious questions about accountability and the commitment to improving maternal healthcare.
The analysis revealed that two-thirds of maternal deaths occurred in hospital settings,with over half taking place after childbirth. The leading causes of these tragic losses were haemorrhage, complications arising during early pregnancy, and suicide. Coroners consistently raised concerns about inadequate treatment, failures to escalate critical cases, and insufficient training among healthcare professionals.
Despite a legal requirement for NHS organizations to respond to coroner’s reports within 56 days, the study found that only 38% of PFDs received published responses from the organizations to whom they were addressed. This widespread non-compliance suggests a deeply ingrained issue within the system.
The findings echo broader global concerns about maternal mortality. According to the World Health Organization, approximately 260,000 women die during and after pregnancy and childbirth annually, with the vast majority of these deaths being preventable. While the risk is highest in lower and middle-income countries – averaging 10 deaths per 100,000 live births in wealthier nations – the situation in England is also cause for alarm. The maternal death rate in England for the period 2021/23 was recorded at 12.82 deaths per 100,000 births.
The urgency of the situation prompted Health Secretary Wes Streeting to announce an inquiry into NHS maternity services in England in june, following a series of documented failings.
“The voices of mothers and pregnant people must be taken seriously,” stated Dr. Georgia Richards, research fellow at King’s faculty of life sciences and medicine and lead author of the study. “Until than, 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 personal toll of these systemic failures was powerfully illustrated by Richard Baish, advancement manager at Action on Postpartum Psychosis, whose wife, Alex, tragically died by suicide in 2022 after giving birth to 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,” Baish explained. “There were no red flags for Alex, which is why it was so tragic her GP didn’t listen to her. Alex was acting strangely and that was the siren for help. If lessons aren’t being learned then it’s likely other women like alex are slipping through the net.”
A spokesperson from the national maternity and neonatal investigation affirmed that the independent investigation will prioritize identifying systemic issues contributing to poor outcomes, including deaths, and will center the lived experiences of women, babies, and families.
The Department of Health and Social Care acknowledged that the lack of response to PFDs is “unacceptable.” A spokesperson stated, “Too many families have been devastated by serious failings in NHS maternity and neonatal care. That is why we have commissioned an urgent national independent investigation and are setting up a taskforce, chaired by the secretary of state, to root out systemic failures and deliver a plan for real change in maternity and neonatal care across the country. we are also taking immediate action to improve safety across maternity and neonatal care, including through advanced monitoring systems and programmes to prevent brain injuries during childbirth.”
The study underscores the critical need for a fundamental shift in how the NHS responds to warnings about maternal care, ensuring that the voices of those affected are heard and that preventative measures are implemented effectively to protect future generations.
