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Two-Thirds of Maternal Death Advice Unheeded
19 Nov
Summary
- Nearly two-thirds of coroner reports on maternal deaths were not acted upon.
- Most maternal deaths occurred in hospitals after childbirth.
- Common causes included hemorrhage, early pregnancy issues, and suicide.
A concerning study from King's College London reveals that advice from coroners intended to prevent maternal deaths is largely being disregarded. Researchers found that almost two-thirds of 'prevention of future deaths' (PFD) reports issued between 2013 and 2023 were not systematically acted upon across England and Wales.
The study, published in BMJ Gynecology and Obstetrics Clinical Medicine, identified 29 PFDs related to maternal fatalities. A significant majority of these reports, highlighting concerns such as inadequate treatment escalation and training deficiencies, received no published response from the relevant NHS organizations within the legally required 56 days. This lack of response means critical safety recommendations are being overlooked.
The majority of these tragic maternal deaths, including those from hemorrhage and suicide, occurred within hospital settings, predominantly after childbirth. In response to these findings and broader concerns about maternity services, the health secretary has announced an investigation, emphasizing the need to address systemic failures and prevent further preventable deaths.
