Coroners Warnings on Preventing Maternal Deaths in England and Wales Often Go Ignored

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Full Story

Coroners advice on maternal deaths in England and Wales is routinely ignored, with nearly two-thirds of prevention reports not acted upon, researchers found. The study examined cases from 2013 to 2023 and noted reports are not used systematically nationally. This highlights gaps in learning from tragedies to improve care.

Maternal deaths occur during pregnancy or shortly after birth. Coroners issue prevention of future deaths reports when issues arise.

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The Context

Researchers at King’s College London analyzed these official reports. They covered pregnant women and new mothers over a decade.

Nearly two-thirds of the reports received no national follow-up action. Advice aimed to stop similar deaths from happening again.

England and Wales have systems to review perinatal fatalities. Better implementation could enhance safety in maternity services.

Families affected push for stronger responses to coroners recommendations. Healthcare providers seek clear guidance to make changes effectively.

Some praise coroners for identifying risks in individual cases. Others point to resource limits hindering widespread adoption of advice.

Campaigners argue ignoring reports dishonors women who died unnecessarily. Officials maintain efforts exist but need better coordination.