Coroner Warnings Ignored, Families Suffer

Advice from coroners intended to prevent future maternal deaths in England and Wales is being consistently overlooked, according to recent findings. This pattern of inaction follows serious systemic failings within healthcare trusts, leaving families to grapple with profound grief.

The Saunders family tragically lost their daughter Juliet due to a hospital misdiagnosis and unsafe discharge. An inquest revealed significant clinical errors and neglect, prompting the coroner to issue eight recommendations. Despite these, the trust initially resisted, questioning the treatability of non-verbal patients, and there was no legal enforcement of promised changes.