Nearly two-thirds of 'prevention of future deaths' reports issued by coroners in England and Wales regarding maternal deaths are not acted upon, according to a study by King's College London. The research, published in BMJ Gynecology and Obstetrics Clinical Medicine, examined 29 such reports from 2013 to 2023 and found that they were not being 'systematically used nationally'.
The study revealed that two-thirds of the maternal deaths occurred in hospitals, with over half of the women dying after giving birth. Common causes included haemorrhage, early pregnancy complications, and suicide. Coroners frequently raised concerns about failures to provide appropriate treatment, escalate cases, and a lack of training.
Although NHS organisations are legally required to respond to coroners within 56 days, only 38% of the reports had published responses. Dr Georgia Richards, lead author, stated that the findings should be used to address failings and prevent similar deaths, urging that the voices of mothers and pregnant people be taken seriously.
Richard Baish, whose wife Alex died by suicide after childbirth in 2022, highlighted the dangers of postpartum psychosis being dismissed as 'baby blues'. He stressed that lessons must be learned to prevent other women from slipping through the net.
A Department of Health and Social Care spokesperson called it 'unacceptable' for organisations not to respond promptly, noting that an independent investigation into NHS maternity services has been commissioned. The investigation will review relevant prevention of future death reports as part of its work.
