🔗 Share this article Coroners' Advice on Maternal Deaths in England and Wales Frequently Overlooked, Research Shows New research indicates that avoidance guidance issued by medical examiners after maternal deaths in England and Wales are not being acted upon. Key Findings from the Research Researchers from a leading London university analyzed 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, found 29 prevention of future death reports related to maternal deaths, but discovered that nearly two-thirds of these suggestions were overlooked. Concerning Statistics and Trends Two-thirds of these fatalities occurred in medical facilities, with more than half of the women passing away post-delivery. The primary causes of death were: Severe bleeding Problems during the first trimester Self-harm Medical Examiners' Main Worries Issues highlighted by coroners most frequently included: Inability to provide appropriate care Absence of case escalation Inadequate medical training Response Rates and Regulatory Requirements NHS organisations, like other professional bodies, are legally required to reply to the coroner within 56 days. However, the research discovered that only 38% of prevention reports had publicly available replies from the organizations they were addressed to. Worldwide and Local Context Based on latest data from the WHO, about 260,000 women died during and after childbirth and pregnancy, even though the majority 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 developed nations is on average 10 per 100,000 births. In the UK, the maternal death rate for 2021/23 was 12.82 per 100,000 live births. Expert Perspective "The voices of parents and pregnant people must be taken seriously," stated the lead author of the research. The researcher emphasized that prevention reports should be included as part of the upcoming independent investigation into maternity services to ensure that the same failures and fatalities do not occur again. Personal Loss Illustrates Systemic Issues One family member shared their experience: "Postpartum psychosis can be life-threatening if not dealt with swiftly and appropriately." They continued: "If lessons aren't being learned then it's likely other mothers are slipping through the net." Official 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 negative results, including fatalities, in maternal healthcare." A government health department spokesperson characterized the failure of institutions to respond quickly to PFDs as "unreasonable." They stated: "Authorities are taking immediate action to enhance security across maternal healthcare, including through sophisticated tracking technology and programmes to avoid neurological damage during childbirth."