Coroners’ advice on maternal deaths in England and Wales routinely ignored, study finds | NHS
The research shows that advice given by coroners in England and Wales to help prevent maternal deaths is not being followed.
Academics at King’s College London examined prevention of future death (PFD) reports issued by coroners in cases of pregnant women and new mothers who died between 2013 and 2023. They found that these reports were “not systematically used at the national level.”
to workThe research, published in the journal BMJ Gynecology and Obstetrics Clinical Medicine, identified 29 PFDs involving maternal deaths, but found that almost two-thirds of these reports were ignored.
Two-thirds of deaths occurred in hospitals; More than half of the women died after giving birth. The most common causes of death were bleeding, complications during early pregnancy, and suicide.
Among the concerns voiced by coroners most frequently were failure to provide appropriate treatment or escalation of cases and lack of training.
Like other professional bodies, NHS organizations are legally required to respond to the coroner within 56 days, but the study found that only 38% of PFDs issued a response from the organizations to which they were sent.
According to the latest figures of the World Health Organization; approximately 260,000 women died during and after pregnancy and childbirthAlthough most of these cases are preventable. While the majority of maternal deaths occur in low- and middle-income countries, in wealthier countries the risk of maternal death averages 10 per 100,000 live births.
The 2021/23 maternal mortality rate in England was 12.82 per 100,000 births. In June, health secretary Wes Streeting announced an investigation into NHS maternity services in England following a series of failures in the healthcare system.
Dr D., a research fellow at King’s School of Life Sciences and Medicine and lead author of the study. Georgia Richards said the findings should be used to address failures and accelerate efforts to prevent similar deaths.
“The voices of mothers and pregnant women must be taken seriously. Until then, PFDs must be included as part of the upcoming independent inquiry into NHS maternity and newborn care by Baroness Amos to ensure the same failures and deaths do not happen again.”
Richard Baish, development director at Action on Postpartum Psychosis, whose wife Alex killed herself after the birth of their daughter Rosie in 2022, said: “Baby blues is used as a throwaway term, but postpartum psychosis can be life-threatening if not addressed quickly and appropriately.
“There were no red flags for Alex, so it was tragic that her doctor didn’t listen to her. Alex was acting strange and this was a cry for help. If lessons aren’t learned, then it’s likely that other women like Alex will escape the net.”
a spokesperson national maternity and newborn survey He said: “The aim of the independent investigation is to identify systemic problems in maternity and neonatal care across England that are leading to poor outcomes, including deaths.
“The lived experiences of women, babies and families are absolutely at the heart of this. The inquest will review reports relevant to preventing future deaths.”
A Department of Health and Social Care spokesman said it was “unacceptable” that organizations did not respond promptly to PFDs.
“Too many families have been devastated by serious failings in the NHS’s maternity and newborn care,” they said. “That’s why we’ve launched an urgent national independent inquiry and are setting up a task force, chaired by the Secretary of State, to root out systemic failings and deliver a plan for real change in maternity and newborn care across the country.
“We are also taking immediate action to improve safety in maternal and newborn care, including improved monitoring systems and programs to prevent brain injuries during birth.”
