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.

This neglect disproportionately impacts individuals with learning disabilities, who are over three times more likely to die from treatable causes. The Saunders family advocates for legally binding enforcement of coroners' prevention of future deaths reports, seeking to spare other parents the agony of losing a child to avoidable healthcare failures.