🔗 Share this article

New academic investigation suggests that prevention guidance issued by coroners following maternal deaths in England and Wales are not being implemented.

Major Discoveries from the Study

Researchers from a leading London university analyzed PFD documents released by medical examiners concerning pregnant women and new mothers who passed away between 2013 and 2023.

The research, released in a prominent medical journal, identified 29 prevention of future death reports related to maternal deaths, but discovered that approximately 65% of these suggestions were ignored.

Concerning Statistics and Patterns

66% of these deaths occurred in hospitals, with more than half of the women passing away post-delivery.

The primary reasons of death included:

• Haemorrhage
• Problems during the first trimester
• Self-harm

Medical Examiners' Main Worries

Problems raised by coroners commonly featured:

• Inability to provide appropriate care
• Absence of referral to specialists
• Inadequate staff training

Compliance Rates and Regulatory Obligations

Healthcare providers, similar to other regulatory organizations, are legally required to reply to the coroner within 56 days.

However, the study found that merely 38 percent of PFDs had published responses from the organizations they were sent to.

Worldwide and National Context

According to recent data from the World Health Organization, about 260,000 women died during and after childbirth and pregnancy, even though most of these instances could have been avoided.

While the vast majority of maternal deaths occur in lower and middle-income countries, the risk of maternal mortality in wealthier countries is on average 10 per 100,000 births.

In England, the maternal mortality rate for 2021/23 was 12.82 per 100,000 live births.

Expert Perspective

"The concerns of mothers and expectant individuals must be given proper attention," stated the principal researcher of the research.

The researcher emphasized that PFDs should be incorporated as part of the upcoming independent investigation into NHS maternity and neonatal care to ensure that the same failures and fatalities do not occur again.

Personal Loss Illustrates Widespread Issues

One family member described their experience: "Postpartum psychosis can be life-threatening if not handled quickly and properly."

They added: "If lessons aren't being learned then it's likely other mothers are slipping through the net."

Official Reaction

A representative from the national maternity investigation stated: "The aim of the official review is to pinpoint the systemic issues that have caused poor outcomes, including deaths, in maternal healthcare."

A government health department official described the inability of organizations to respond promptly to PFDs as "unacceptable."

They confirmed: "We are implementing urgent measures to enhance security across maternal healthcare, including through sophisticated tracking technology and initiatives to avoid brain injuries during delivery."