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New research suggests that avoidance recommendations issued by coroners after maternal deaths in England and Wales are not being acted upon.

Key Findings from the Research

Academics from a leading London university examined PFD documents released by coroners concerning pregnant women and new mothers who passed away between 2013 and 2023.

The research, released in a prominent medical journal, identified 29 PFDs involving maternal deaths, but discovered that approximately 65% of these suggestions were overlooked.

Concerning Statistics and Trends

66% of these deaths took place in medical facilities, with over 50% of the women dying after giving birth.

The most common causes of death included:

• Haemorrhage
• Problems during early pregnancy
• Suicide

Coroners' Primary Concerns

Issues highlighted by medical examiners commonly included:

• Failure to provide appropriate treatment
• Lack of referral to specialists
• Insufficient staff training

Response Rates and Legal Requirements

NHS organisations, similar to other regulatory organizations, are mandated by law to reply to the medical examiner within 56 days.

However, the study discovered that only 38% of PFDs had published replies from the institutions they were sent to.

Global and National Perspective

According to latest data from the WHO, about two hundred sixty thousand women died throughout and following childbirth and pregnancy, even though the majority of these cases could have been prevented.

While the overwhelming majority of maternal deaths occur in developing nations, the danger of maternal death in wealthier countries is on average 10 per 100,000 live births.

In England, the maternal mortality rate for 2021/23 was twelve point eight two per hundred thousand live births.

Professional Perspective

"The voices of parents and pregnant people must be taken seriously," commented the principal researcher of the research.

The academic emphasized that PFDs should be included as part of the upcoming independent investigation into maternity services to ensure that the same failures and deaths do not happen repeatedly.

Individual Loss Illustrates Systemic Problems

One family member shared their story: "Postpartum psychosis can be fatal if not dealt with swiftly and appropriately."

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

Formal Response

A representative from the national maternity investigation said: "The aim of the official review is to pinpoint the underlying problems that have led to poor outcomes, including deaths, in maternal healthcare."

A government health department spokesperson characterized the inability of organizations to reply promptly to prevention reports as "unacceptable."

They confirmed: "We are implementing urgent measures to improve safety across maternity and neonatal care, including through advanced monitoring systems and programmes to prevent neurological damage during childbirth."