What are PFD reports in the context of maternal deaths?

PFD reports are issued by coroners to highlight actions needed to prevent future deaths after an investigation into a fatality.

Why is King's College London studying maternal deaths?

The study aims to identify systemic gaps in care and ensure recommendations from PFD reports are acted upon to save lives.

What are the main causes of maternal death in England and Wales?

The leading causes identified in recent reports include haemorrhage, suicide, and complications in early pregnancy.

Home / Health / Maternal Deaths: Coroner Advice Ignored?

Maternal Deaths: Coroner Advice Ignored?

19 Nov, 2025

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Summary

Coroner recommendations to prevent maternal deaths are not being systematically applied nationally.
Haemorrhage and suicide are leading causes of maternal fatalities identified in reports.
Only 38% of critical PFD reports received published responses from relevant organizations.

Maternal Deaths: Coroner Advice Ignored?

A concerning study from King's College London indicates that crucial recommendations made by coroners to prevent maternal deaths are not being consistently implemented across England and Wales. Researchers analyzed Prevention of Future Deaths (PFD) reports, finding that identified care gaps are not systematically used to avert further tragedies. These PFDs arose from cases where mothers died, with haemorrhage and suicide cited as major causes.