Coroners' advice to prevent future maternal deaths is not being acted upon, say researchers.
The study, authored by Dr Georgia Richards, founder of the Preventable Deaths Tracker at King's and published in Gynecology and Obstetrics Clinical Medicine, finds coroners concerns are being ignored despite raising repeated issues about maternal deaths.
Dr Richards and her team identified 29 Prevention of Future Deaths reports (PFDs) written by coroners during or following inquests in England and Wales between 2013-2023, which mentioned a maternal death that occurred during pregnancy, childbirth or in the post-partum period to identify trends that could save lives.
Maternal deaths are reported to MBRRACE-UK and in 2021-23, the maternal death rate was 12.82 per 100,000 women giving birth. Separately coroners in England and Wales have a duty to write PFDs when they believe that action should be taken to prevent similar deaths. In reality, just 1% of maternal deaths in the UK reported to MBRRACE were written as a PFD.
In the reports, coroners frequently voiced concerns around the failure to provide appropriate treatment (48.2%), the failure to escalate (38%), recognition of risk factors (31%), and lack of training (37.9%).
Two thirds of deaths occurred in hospitals, of which 27% were caused by haemorrhage, 20% in early pregnancy which included complications of ectopic pregnancies and terminations, and 20% were suicide. More than half (55%) occurred postpartum, including psychiatric causes and those occurring after abortion, or surgery for ectopic pregnancy. The median age of death was 33.5 years with one death in a person aged under 17.
PFDs are sent to organisations including NHS trusts and professional bodies such as Royal Colleges. By law, organisations are required to respond to the coroner within 56 days, but the study found 62% of PFDs were unanswered.
Every maternal death is a tragedy, a failure to the mother, their family and their child. By tracking PFDs following maternal deaths, we can identify repeated concerns and gaps where organisations should act to save lives.
Dr Georgia Richards, Research Fellow in the Faculty of Life Sciences and Medicine
She added: "These insights should not be used to terrify people giving birth or new and soon-to-be mothers. Instead, it should be used for action, to continue and accelerate ongoing efforts that must improve how people are treated and managed during this period.
"The gaps recognised by coroners during death investigations are not being systematically used nationally, we identified trends and patterns that must be addressed, and routinely monitored, to prevent similar deaths.
"The voices of mothers and pregnant people must be taken seriously. Until then, PFDs should be included as part of the upcoming independent investigation into NHS maternity and neonatal care by Baroness Amos to ensure that the same failures and deaths do not occur again."
